Instructor's Guide Postitive Learning: An Alternative to Behavior Management by Wade Hitzing, Ph.D. Produced by The Minnesota Governor's Planning Council on Developmental Disabilities Graphic Design, Editing, Production by Carol Kittelson and Janet Leadholm Kittelson & Leadholm Course Design by Qu Learning Systems, Inc. Photography by Ann Marsden Acknowledgment to: Colleen Wleck, Ph. D. Executive Director Developmental Disabilities Council David Hancox Training Director Miriam Karlins special Consultant The information in this manual is based on projects funded by the Ohio Developmental Disabilities Planning Council and conducted by the Ohio Society for Autistic Citizens. The projects focused on increasing the competence of Ohio's communities to support persons with challenging behavior. The Editorial Review Board: Peter Ampe Rick Amado, Ph.D. Dean Barr Wendy Bartzh Roger Betz Ron Rucker Paul Thorenson For more information, contact: Minnesota Governor's Planning Council on Developmental Disabilities, 300 Centennial Off3ce Building, 658 Cedar Street, St. Paul, Minnesota 55155 (612) 296-4018 Of (612)296-9962 TDD Behavior NOTES ON USING THIS MANUAL COURSE OUTLINE COURSE GOALS AND OBJECTIVES Session 1 NOTES AND CONTENT SECTION A: Introduction SECTION B: A Common Story SECTION C: Discussion of A Common Story SECTION D: Great and Desperate Cures SECTION E: Videotape "An Elephant at Mouse Place" SECTION F: Ralph's Story SECTION G: Ralph's Story Exercise SE(XION H: Sumrnary and Closing Session 2 NOTES AND CONTENT SECTION A: Introduction to Session 2 SECTION B: Summary of Ralph's Story SECTION C: Understanding Behavior Challenges SECTION D: Understanding Reasons for Behavior SECTION E: Supporting Learning vs. Managing Behavior SECH'ION F: Kathy's Story Exercise SECTION G: Course Summary OVERHEADS WORKSHEETS / HANDOUTS RESOURCES Notes On Using This Manual The content upon which this course is based is found in the inside column of each page, Instructor's notes and guidelines appear in the outside column. These notes are intended to help less-experienced instructors create an interesting and effective classroom experience. More experienced instructors may feel free to add their own ideas, Overheads and handouts are provided to help reinforce key points. This course is designed to be delivered in two four-hour sessions, but can be combined into one eight-hour session. Notes To Instructor This course has been specifically developed to help people responsible for providing direct care to individuals with severe disabilities understand and participate in an alternate approach to Behavior Management. This course is organized into a total of 15 sections. Overheads and several videos which can be used to augment the lecture or to demonstrate a particular technique are incorporated into the course. The time recommended for each section is provided in the notes that preface the sections. Before teaching this course we recommend that you become familiar with all of this material, review all videos and tapes plus the handbooks which go with some of the videos. Behavior Notes Format This course is designed to be delivered via a combination of lecture, slide or videotape presentations, large and small group discussions, and role playing. As you study the various classroom sections, you will notice that the role playing segments call for participation by at least three individuals. If your class size is too small to permit that level of participation and still generate adequate discussion, you may have to modify your delivery. In some cases, existing videotape presentations may be substituted. You may wish to develop your own videotape using a home video. camera with friends and associates serving as your cast. Time This course is designed for a total of eight hours of classroom instruction divided into two four-hour sessions to be held on two different dates. You may find that your specific circumstances demand delivery over a different time frame. The course may easily be combined into one-day long session with a lunch break. Additionally, while this course has been developed for stand-alone delivery, it may be combined with additional material as part of a more comprehensive course in the support of individuals with disabilities. 2 Behavior Notes MateriaIs Originals of all required visual aids, overheads, and handouts are included in this manual. In order to deliver this material as designed, you will have to make overhead copies of these originals and sufficient copies of all handout materials for your class. In addition, the following equipment is required: 1. Overhead projector. 2. Projection screen. 3. VHS format video cassette recorder (VCR) or video playback unit. 4. Markerboard or flip chart pad with easel. 5. Two or three colored markers. 3 Course Outline SESSION 1 A. INTRODUCTION Lecture, 5 minutes B. "A COMMON STORY" Lecture, 20 minutes C. DISCUSSION OF "A COMMON STORY" Large and small group discussion, 60 minutes D. GREAT AND DESPERATE CURES Lecture/discussion, 45 minutes E. VIDEOTAPE: "AN ELEPHANT AT MOUSE PLACE" Video tape/discussion, 30 minutes F. RALPH'S STORY Lecture, 30 minutes G. RALPH'S STORY EXERCISE Individual/Small-group exercise, 80 minutes F. SUMMARY AND CLOSING Lecture, 10 minutes 5 Behavior Course Outline SESSION 2 A. INTRODUCTION TO SESSION 2 Lecture, 10 minutes B. SUMMARY OF RALPH'S STORY EXERCISE Lecture/discussion, 15 to 60 minutes C. UNDERSTANDING BEHAVIOR CHALLENGES Lecture/discussion, 30 minutes D. UNDERSTANDING REASONS FOR BEHAVIOR Small-group activity, 30 minutes E. SUPPORTING LEARNING VS. MANAGING BEHAVIOR Lecture/discussion, 45 to 55 minutes F. KATHY'S STORY EXERCISE Small-group exercise, 50 minutes G. COURSE SUMMARY Lecture, 20 minutes 7 Course Goals & Objectives UPON COMPLETION OF THIS COURSE, STUDENTS SHOULD BE ABLE TO: 1.0 Understand that challenging behavior has a strong communicative function and that people often respond in a disruptive, dangerous rnamer because we are not providing supports and services that meet their needs. 1.1 Recognize that before implementing a plan to decrease the person's challenging behavior, they must look comprehensively at the person's life and attempt to identify all the factors that are contributing to the problem behavior. 1.2 Recognize that traditional behavior plans, especially those that focus on providing rewards or punishments, usually ignore (leave unchanged) many of the factors which are causing the problem behavior. 1.3 Understand that we often are "FORCED" to implement more aversive and restrictive behavior change procedures, than might be necessary, because important factors causing the problem behavior are ignored. 1.4 State the importance of the communicative intent of most problem behavior and the necessity of f~st attempting to meet the person's needs before trying to change hedhis behavior. 2.0 Understand that there are no "GREAT AND DESPERATE CURES." Helping another person change his/her behavior will probably require a comprehensive plan that deals with all major aspects of the person's life. 2.1 Recognize that in the history of services for people with challenging behavior there are many examples of mis~ided efforts to find a "CURE," a "QUICK FIX' for problem behavior. 9 Behavior Goals & Objectives 2.2 Recognize that this tendency to seek simple, easy solutions for complex, difficult problems can be also be seen in other areas of human behavior - such as weight control. 2.3 Understand the importance of avoiding the use of behavior plans in a "QUICK WEIGHT LOSS" approach to behavior change. 2.4 Understand that a good service plan begins with efforts to support the person and provide services that meet the her/his needs before implementing teaching plans to change the person's behavior. 3.0 Recognize that when challenging behavior is caused at least in part by an inadequate program of supports and services, we must attempt to first individualize these services to better meet the person's needs. This strategy is in contrast to the more traditional approach of implementing a behavior plan that focuses on decreasing specific "TARGET BEHAVIORS" through a series of rewards and punishments. 3.1 Recognize that it can be difficult to support people with challenging behavior because most community-based programs were not designed to meet their needs. 3.2 Understand that most challenging behavior makes sense, from the point of view of the person engaged in it, especially when you realize how far our services are from meeting the needs of the person with challenging behavior. 3.3 Through the Practicum Exercise, increase their skills in advocating for people with challenging behavior by giving them experience in: Figuring out why people engage in challenging behavior. Explaining to others why people engage in challenging behavior. 4.0 Recognize that there are causes for challenging behavior - especially with respect to environmental influences that precede and follow behavior. 10 Behavior Goals & Objectives 4.1 Recognize that there are always reasons for why people do what they do; there are causes for challenging behavior. 4.2 Understand that the fmt step to helping decrease behavior challenges is to understand the cause(s) for the behavior. 4.3 Understand that while there are physical causes for challenging behavior, they are rarely the cause for the challenging behavior. 4.4 Describe the major environmental causes for challenging behavior, through the use of the "VICIOUS CYCLE DIAGRAM." 4.5 Differentiate between environmental influences that precede (antecedents) versus follow (consequences) the behavior. 4.6 Understand that most challenging behavior is learned and that "WE" are the ones who teach it. 4.7Look at the situation from the person's point of view, "LISTEN TO" the person's challenging behavior and understand what the person is trying to communicate. 5.0 Distinguish between simply managing a person's behavior versus supporting her/him in learning to change through listening, negotiation and effective positive teaching strategies. 5.1 Discriminate between simply managing a person's behavior, usually to decrease problem behavior, versus supporting the person in learning more appropriate behaviors. 5.2 Recognize that they should always begin by attempting to support the person in learning more appropriate behaviors by changing services to better meet the needs of the person and teach alternative behaviors. 5.3 Determine that often the major "PROBLEM" they should deal with is not the challenging behavior of the person; rather it is the fact that the person has been provided services which are not individualized and do not meet his/her needs. 11 Session 1. Notes and Content Behavior Session 1 Introduction Format Lecture Time 5 minutes Materials Overhead 1 Behavior Session 1 Behavior Session 1 Notes 1. Introduce yourself and have the students introduce themselves. 2. Disploy Overhead 1, course goals. In clear terms that the students can easily understand, list the goals of the course. Behavior Session 1 Format Lecture Time 20 minutes Materials Overheads 2-8 Handout 1- A Common Story Behavior Session 1 Objectives Upon completion of this section, students should be able to: 1.1 Recognize that before implementing a plan to decrease the person's challenging behavior, they must look comprehensively at the person's life and attempt to identifi all the factors that are contributing to the problem behavior. 1.2 Recognize that traditioml behavior plans, especially those that focus on providing rewards or punishments, usually ignore (leave unchanged) many of the factors which are causing the problem behavior. 1.3 Understand that we often are "forced" to implement more aversive and restrictive behavior change procedures, than might be necessary, because important factors causing the problem behavior are ignored. 1.4 State the importance of the communicative intent of most problem behaviors and the necessity of first attempting to meet the person's needs before trying to change her/his behavior. Behavior Session 1 Section B: Content "A COMMON STORY" At a regional training conference several years ago, the organizers arranged for an evening session during which the participants could talk informally with the presenters about working with people with challenging behaviors. The participants wanted to describe the problems they faced and hoped that the presenters would have something to share that might help them do a better job. The presenters were not sure they helped anyone that night. But they learned a very important lesson. They learned the lesson because five different people told them the "same" story. The specifics of each story were of course different - but the fundamental message was the same. Here is what happened. Each participant began his or her story by describing a person with challenging behavior. Each person was different, as were their behaviors. One fellow was described as having severe temper tantrums, a woman hit herself in the head repeatedly, a student bit and kicked other students, etc. Each was the subject of a behavior plan designed to decrease or eliminate the challenging behavior. Notes 1. Tell "A Common Story" to the students, using overheads 2 - 8. 2. Ask the students to indicate by show of hand whether the questions included toward the end of the story are true for them. Don't make comments - just have them notice whether that's happened for them. 19 Behavior Session 1 FOR EXAMPLE: The man with the severe temper tantrums was being forced to sit alone in an empty room, for 15 minutes, if he cried (a time out program). The woman who was self-injurious was ignored when she hit herself (an extinction program). She was frequently praised when she did not hit herself. The student earned tokens when he did not act aggressively towards other students and was denied access to his favorite activity when he did (a DRO/punishment program). Each of the participants explained that they were not totally happy with the results of the plans. The behavior of some of the people had improved after the plans were implemented, but not enough to be satisfied with the results. For example, one of the participants (Mr. Louis) worked in a group home and he described a man (Bob), with severe temper tantrums. He said that while the time out program had reduced the frequency of temper tantrums by 50Y0, Bob was still having seven to ten tantfums each week. The tantrums were described as a serious problem. Mr. Louis said that if it weren't for the tantrums Bob could move to an apartment living program - which he really wanted to do. Mr. Louis wanted to know if the program was appropriate for Bob - had any chance of working more effectively, etc. But first, he said "Wait, before you answer, there are a few more things you need to know about Bob." 20 Behavior Session 1 YOU NEED TO KNOW THAT: "Bob lives in the `wrong' place." He used to live in an apartment of his own but he lost his job and couldn't afford to stay there. Our group home was the only available placement. "Bob lives with the 'wrong' people." The other men in the group home all have mental retardation and are far less skilled than he is. He refuses even to admit that he is mentally retarded and wants nothing to do with his housernates. "We don't have enough staff." In addition to the tantrums, Bob steals from his housernates. We don't have enough staff to provide for appropriate supervision. "We haven't had appropriate tmining." Bob has very limited speech, but hardly any of the staff know how to sign. The psychologist says that Bob has serious mental health problems - we don't know what that means. "He hates his day program at the workshop." When Bob lived in the apartment he had a good job working for a landscaping company. He lost that job when he was moved to the group home - he couldn't get to work on time from our side of town. He hates "sit down - packaging" type work. 21 Behavior Session 1 "Now," said Mr. Louis, "you know the whole story. Mpay, we've been thinking of doubling the duration of the time out period from 15 to 30 minutes. What do you think? Might that work?" I am not trying to make fun of Mr. Louis. His question about increasing the time out period might have been misguided but it was sincere. However, he had just clearly described five major problems in Bob's life - each of which was probably contributing directly to temper tantrums. He did not seem to see that the time out program, no matter what the duration, had nothing to do with, and could not help correct, these problems. The presenters didn't know what to say. It wasn't simply that increasing the time out period to 30 minutes was doomed to fail. Maybe if Bob was really afraid of, or hated the isolation, he would have fewer tant.mms. There is no doubt that if we are "bigger," more "powerful" than Bob we can probably devise a sufficiently aversive procedure so that he will learn to stop telling us about what bothers him. No matter how troubling it is to him to live where he is not happy, to live with people he dislikes, to work at a job he finds boring and low paying, we can probably devise a reward or punishment procedure to shut him up. But will we or Bob have gained much? Is there any reason to be happy if the time out program does succeed in eliminating the temper tantrums? Should we celebrate the fact that we have found a way to force a person to live where he doesn't want to, with people he dislikes and to work each day at a job he hates but at the same time keep quiet about it? Of course, the details of each of the other participants' stories were different. But a fundamental theme ran through each of the five stories. 22 Behavior Session 1 STORY THEMES 1. Person with a disability engages in behavior that is disruptive, harmful, dangerous (challenging behavior). 2. Members of the service planning team are usually aware of factors in the person's life that are contributing to the challenging behavior. 23 Behavior Session 1 3. A Behavior Plan is implemented to ciecrease the targeted behaviors. The Plan usually involves some combination of the following: Elimimting any reinforcement for the "PROBLEM" behavior (extinction). Making sure that the consequences of the target behavior are unpleasant, through the use of privilege removal, restrictions, painful stimuli, etc. Providing powerful rewards for not engaging in the "PROBLEM" behavior. 4. If plan does not produce the desired changes, the "POWER" of the rewards and punishers is increased. More aversive consequences are used. Items and activities even more important to the person are withheld, to be given later as rewards for appropriate behavior. 5. Throughout the process, factors that are clearly influencing the person's behavior such as where they live, with whom, activity schedules, choices, etc., remain largely unchanged. 6. Far too often the resuhs are: There is not sufficient improvement in the challenging behavior and the person is suspended from the sewice program. The behavior plan is "SUCCESSFUL," but only after very restrictive procedures are implemented. 24 Behavior Session 1 All of the participants showed, in the telling of their stories, that they were aware, at least at . one level, that a number of factors were contributing to the person's challenging behavior. However when it came to actually doing something to help, they acted as if they did not understand. Surely none of the members of Bob's service planning team believed that he was having severe temper tantrums because he had been "DEPRIVED" of time out. In the past, didn't they understand that the use of time out, for whatever duration, would do nothing to alleviate the problems caused by his placement in the group home and work assignment? . YOU MAY BE THINKING: "So what? What is to be gained by acknowledging these other factors? How will this help Bob?" Well, of course there is at least one obvious benefit. If the team clearly acknowledged that Bob's residential and work placement were not meeting his needs, that they needed more trained staff, etc. - they or someone else just might do something about it! People who know a person well and are personally committed to supporting the person can often develop a plan, centered on the specific needs of the person, and help make the kinds of major changes not one of them believed was possible. But you're right if you are thinking that it is often not possible to make immediate changes, even though they may be desperately needed. A very real absence of available alternatives probably did "FORCE" the team to accept Bob's initial placement at the group home and workshop. At the time there probably was not enough money to pay for extra staff or more training. However, unless the team explains, in Bob's plan, that they feel that his challenging behavior is at least partially caused by their weaknesses (inappropriate placement, lack of training, etc.) the needed changes may never be made, even if they become possible. For instance, if funds do become available, why would the administrators of the agency which serves Bob hire extra staff or arrange for advanced staff training - if they believe that Bob simply needs a more powerful behavior plan? If they see the issue as only "BOB'S PROBLEM" not "OUR PROBLEM. " Even if it seems necessary to accept the current situation for the foreseeable future it is still important to acknowledge that we are part of the problem, not just Bob. Have you ever noticed how despite your best intentions you find yourself feeling resentful towards a person with challenging behavior? Especially if you have been a target of their "CHALLENGE?" Ever been mad at the person when a plan that `OUGHT TO WORK" is failing? Clearly some of this is just human nature. It shows you care. But, if we were honest, we would admit that far too often we hold the person responsible for actions that are clearly controlled by conditions we have helped create. Bob did not pick the group home or his housernates. He did not have a chance to vote on the tax levy that failed, causing a cut in the new staff positions., Clearly acknowledging our (the system's) role in contributing to Bob's challenging behavior should help decrease our resentment and increase our motivation to make the changes necessary to be more supportive of Bob and design the kind of individualized services that are necessary to meet his needs. 26 Discussion of "A Common Story" Format Large/small group discussion Time 60 minutes Materials Overheads 9-17 Worksheet 1 27 Behavior Session 1 Objectives Upon completion of this section, students should be able to: 1.1 Recognize that before implementing a plan to decrease the person's challenging behavior, they must look comprehensively at the person's life and attempt to identi~ all the factors that are contributing to the problem behavior. 1.2 Recognize that traditioml behavior plans, especially those that focus on providing rewards or punishments, usually ignore (leave unchanged) many of the factors which are causing the problem behavior. 1.3 Understand that we often are "forced" to implement more aversive and restrictive behavior change procedures, than might be necessary, because important factors causing the problem behavior are ignored. 1.4 State the importance of the communicative intent of most problem behavior and the necessity of first attempting to meet the person's needs before trying,to change her/his behavior. 28 Behavior Session 1 Section Content One of the central themes of this lesson is that the person's challenging behavior is often caused, at least in part, by the fact that the services and supports provided are not individualized and are far from meeting the person's needs. Further, the lesson shows that if these needs are ignored that implementation of a behavior plan may: 1. Not work at all because powerful factors that are influencing the person's behavior remain unchanged. 2. Require the use of restrictive teaching procedures to be effective - again because obvious "CAUSES" for the person's problem behavior are ignored. 1. Make the points listed in the content provided. 29 Behavior Session 1 Note: The exercise described below can be used to reinforce these ideas. The exercise can be used within a lecture or small group discussion session. 2. Ask each participant to think of (select) a person with disabilities who also shows challenging behaviors. Display overhead 9, and ask students to answer three series of questions (Step 1, 2, and Step 3). Explain that you'll provide some examples before they start this exercise. Step 1 "What is it that seems to disturb, frustrate or upset the person?" "Are there situations or settings that seem to disturb or upset the person?" Step 2 "How do you know that the person is disturbed or upset by these situations?" "How did the person let you know that they were upset?" Step 3 "When the person is faced with these types of disturbing or frustrating situations what do you think he/she needs from other people?" "What help or support might the person ask for if she/he could clearly communicate?" 30 Behavior Session 1 HOW TO ANSWER THESE QUESTIONS: Make sure that you try to answer from the person's point of view - not from the point of view of what you think he/she needs. EXAMPLE 1 Step 1 Mary, who has severe hearing and visual impairments, seems to be disturbed at her day program when she becomes confused about what she is supposed to be doing as her work assignment. She also has trouble in making transitions from one assignment to the next. step 2 Mary shows that she is upset or confused by biting her hands, pulling at her hair and sometimes slumping to the floor. step 3 Mary does not talk so the staff had to make their best guess - based on their knowledge of Mary. After thinking about the situation, from Mary's point of view, they guessed that what she would ask for was a clear way to understand what task or activity she was supposed to be working on and a way to know what's next when it was time to change tasks. Simply telling her about it using her limited repertoire of manual signs was not effective so they developed a more "CONCRETE" sign language. 3. Provide examples of how to answer these questions to make sure that the participants understand the intent of the questions. Display overheads 10-15 in sequence as you discuss the examples. Behavior Session 1 They selected objects that were associated with each task or activity and began to systematically use them as prompts for the current activity if she seemed to be confused as she worked and as a cue for the next task when they were changing from one task to another. For example, they used a dinner plate to cue the learning activity for "setting the table," a bar of soap for a self-care activity, and a piece of clothing for a sorting task. These procedures helped Mary a lot - she became upset at times but much less than before. Things improved even more when Mary figured that she could have some control over her schedule of activities by using the "communication objects" to show the staff what she wanted to do. EXAMPLE 2 Step 1 Bob does not do well in noisy situations. He seems to be very sensitive to loud sounds, especially those that he has no control over. Crowds, especially noisy ones really upset him. Behavior Session 1 step 2 Bob doesn't talk but he does let people know he is upset in a variety of different ways. He may put his hands over his ears, begin to yell and even run away. He may attempt to hit the people who are being noisy. If he is in his room he may turn his radio up to "DROWN OUT" the noise of the other people in the group home. step 3 It wasn't hard to figure out that Bob would ask for people to stop making so much noise and to be allowed to spend some time alone or at least with only a few other people. While it wasn't possible to make major changes in where Bob lived and worked staff were able to make a few changes that really seemed to help. Bob switched bedrooms with another resident which helped him be further away from the noise of the home. They also showed Bob how he could use a portable radio with earphones to mask the noise of his co-residents without having to play his stereo so loud that it disturbed everyone else. At work they changed his work setting so that he was removed from the major flow of noise and activity. They also allowed him to wear the earphones at work, which seemed to help there too. Behavior Session 1 4. Hand out the "Common Story Worksheet" for students to use to record their answers. Allow the students at least 10 minutes to complete their answers to the three questions. 5. After the students have written down their individual answers, divide them into groups of two or three and ask them to present their answers to their partner or the other members of their group. It probably does not make sense for them to critique each other's answers; the purpose is to simply have them hear about a wide range of situations. Allow about 5 minutes for this step. 6. Next, ask participants to share interesting examples with the larger group. Allow about 15 minutes for this step. 7. Clearly acknowledge that it is often very difficult to figure out what the person would ask for, what they need - especially for persons who have a hard time understanding. Under these conditions, we make our best bet, act on it and see if we were right. If our guess was correct we continue; if we were wrong we apologize, make another guess and give it another try. 8. Ask the students to raise their hand if they wrote any of the following as answers to Step 3: "He would ask me to put him in the time out room. " "She would ask me to take her radio away. " "He would ask me to ignore him, act like he doesn't exist." 9. It is very unlikely that any of the students will raise their hands. You should then ask them the following question: If none of you gave answers like these for Step 3, then why do we so often implement behavior programs that are consistent with these answers? 34 Behavior Session 1 WHAT YOU ARE ATTEMPTING TO SHOW THE STUDENTS ARE: step 1 There are a variety of different situations, settings, etc., that may disturb or confuse the person. step 2 People "TELL" us about these situations in a variety of different ways. Often this type of communication is labeled as disruptive or inappropriate behavior. step 3 We figure out what the person wants (i.e. how we might help them deal with the situation described in Step 1) the answer is often fairly straight forward. Most students will probably develop answers in Step 3 of the exercise that are reasonably comected to the situations described in Step 1. Of course it may not be possible to always do what the person wants or needs. The point is not whether we can always do what is needed but for the trainees to appreciate the importance of looking at the situation from the person's point of view and how the person's requests for assistance are usually very reasonable and typical of how most people would feel in the same situation. Behavior Session 1 Provide examples as shown on overheads 16 and 17. 10. Ask students if any of them really believe that Bob yells or plays his radio too loud because he hasn't had his radio taken away enough in the past? That we are making up for this neglect by taking his radio away now? Ask if any of them believe that the cause Mary's disruptive behavior at her day program is that she hasn't been punished enough in the past? That Mary yells because she hasn't gotten enough candy for being quiet? EXAMPLES OF AVERSIVE BEHAVIOR MANAGEMENT Step 1 Bob does not do well in noisy situations. He seems to be very sensitive to loud sounds, especially those that he has no control over. Crowds, especially noisy ones really upset him. Step 2 Bob doesn't talk but he does let people know that he is upset in a variety of different ways. He may put his hands over his ears, begin to yell and even run away. He may attempt to hit the people who are being noisy. If he is in his room he may turn his radio up to "drown out" the noise of the other people in the group home. Step 3 Bob's radio is taken away for 15 minutes each time he plays it too loud. If Bob remains agitated he is placed in the time out room until he calms down. ANOTHER EXAMPLE OF AWRSIVE BEHAVIOR MANAGEMENT step 1 Mary, who has severe hearing and visual impairments, seems to be disturbed at her day program when she becomes confused about what she is supposed to be doing as her work assignment. She also has trouble in making transitions from one assignment to the next. 36 Behavior Session 1 Step 2 Mary shows that she is upset or conhed by biting her hands, pulling at her hair and sometimes slumping to the floor. step 3 Mary's teacher sprays a water mist in her face when she pulls her hair or yells. She is given candy for remaining quiet. The concern is not whether the programs will be successful if we define success as a decrease in Mary and Bob's disruptive behavior. We can usually develop a behavior plan that will work. If taking Bob's radio away for 15 minutes is not effective, we can try taking it away for an entire day. If the frequency of Mary's biting does not decrease when we spray her face with water, we can try squirting Tabasco sauce in her mouth. There is little doubt that if we are stronger and more powerful that we will be able to escalate to more restrictive and aversive procedures that will be effective in managing the person's behavior. However, as the written lesson pointed out, Bob and Mary may not see this as a success. Such behavior programs may only be serving to shut the person up about conditions and situations that they find disturbing or confusing. Such behavior plans do nothing to change the original conditions that led to the person learning the disturbing behaviors. 11. Explain what the real concern is. Make it clear to the students that you understand and share their concern about the person's disruptive behavior. It is legitimate for them to be concerned about helping the person learn less disruptive ways to deal with her/his anger and confusion. However, helping the person change his/her behavior should not begin until we have attempted to implement the kinds of changes in our behavior that are usually described in the answers to Step 3 in the process. Great and Desperato Cures Behavior Session 1 Format Lecture/discussion Time 45 minutes Materials Overheads 18-24 Handout 2- "Great and Desperate Cures" Handout 3 - Joey's Story 39 Behavior Session 1 Objectives Upon completion of this section, students should be able to: 2.1 Recognize that in the history of semices for people with challenging behavior there are many examples of misguided efforts to find a "CURE," a "QUICK FIX" for problem behavior. 2.2 Recognize that this tendency to seek simple, easy solutions for complex, difficult problems can be also be seen in other areas of human behavior - such as weight control. 2.3 Understand the importance of avoiding the use of behavior plans in a "QUICK WEIGHT LOSS" approach to behavior change. 2.4 Understand that a good sexvice plan begins with efforts to support the person and provide services that meet the her/his needs before implementing teaching plans to change the person's behavior. 40 Behavior Session 1 Section D: Content The history of human services is filled with many different ways we have tried to "CURE" people with disabilities - especially people with disruptive, dangerous, challenging behavior. Valenstein has written a book titled "GREAT AND DESPERATE CURESn that provides examples such as: In the late 1800s a German neurologist published book on electrotherapy. Weak electric currents were used to "stimulate the patient's nervous system" and improve behavior. Electrical stimulation device invented by Dr. John Butler of New York. It was said to be "especially salubrious in cases of rheumatism, nervous exhaustion, neuralgia and paralysis. (From Harper's, 1881) Notes 1. Present "Great and Desperate Cures," using content provided and overheads 18 - 23. Behavior Session 1 . Hydrotherapy, which involved baths, douches, wet packs, steam and hoses was also used frequently in the early 1900s. In the late 1800s, a psychiatrist inoculated patients in mental hospitals with vaccines of tuberculosis, typhoid fever, malaria and other infectious diseases. His theory was that high fever, brought on by the infections, cured his patients. He became very famous and was also very wrong. Later hot baths, hot air, radiothermy, infrared-light bulb cabinets and special electric "mummy bags" were also used to induce high body temperatures. These "treatments" were less deadly but did little other than make the people very hot. Sleep therapy or "prolonged narcosis" was used in the 1920s and 30s. Drugs were used to keep patients in mental hospitals unconscious, usually for one or two weeks - sometimes as long as a month. "Cure" rates of 7ov0 t. 8(YMo were repotied. Other therapies have included: Using small doses of cyanide to stimulate the nervous system inducing aseptic meningitis Hypothermia, cooling the body Electroconvtdsive therapy Lobotomies 42 Behavior Session 1 BEFORE YOU THINK TOO HARSHLY OF OUR ANCESTORS LOOK AROUND, NOW. WHAT ARE OUR "GREAT AND DESPERATE CURES?" Universal Press Syndicate 43 Behavior Session 1 Behavior Session 1 The need to find THE "KEY TO THE PROBLEM," the "ONE THING THAT WILL SUCCEED" is clearly with us still today. This notion of a quick, dramatic solution, is not limited to the field of human services. Look at the advertisement on this page. Behavior Session 1 Anyone with even a basic understanding of nutrition knows that the way to stay healthy, keep control of your weight is to follow these guidelines: Eat well balanced meals. Don't eat too much. Exercise regularly. Get enough sleep. Don't smoke. Drink, if at all, only in moderation. We all know that these guidelines are true, yet many of us often act as if they weren't. We eat too much. We smoke. We drink too much alcohol. Our major recreation is watching other people exercise on T.V. We know the guidelines are true but we also have experience that says they are difficult to follow. It is one thing to know that you should not eat too much and it's another thing to say NO to the banana cream pie. We want the advertisement on the overhead to be true. If it were true we could ignore the nutrition/exercise guidelines and just buy the "MAGIC BULLET' diet pills. This kind of thinking maintains our multi-billion dollar diet industry. 46 Behavior Session 1 It is true that a sensible diet can help some people, some of the time. It might help a person lose weight - but we all know that to rmiintain our health takes a lot of work and requires us to look at and possibly change many different aspects of our life. Still, we hold out hope for the special, miracle diet. Some of you are probably wondering right now, about how you might order the "FAT- AWAY MAGIC BULLETS," even at $10 a pill. PEOPLE WITH CHALLENGING BEHAVIOR Given the above way of thinking, is it too surprising that when we are faced with helping support a person with disabilities who has severe behavior challenges that we adopt the: Quick Weight Loss Approach to Behavior Change There is a very strong parallel between the concept of a diet and that of a behavior plan. The ideal diet is one that requires very little of the user - few, if any, major changes in eating habits, no exercise - but still produces quick, dramatic results. Similarly the "IDEAL" behavior plan is one that requires very little change in our (the system's) behavior. It is easy to implement, yet results in quick, dramatic reductions in or elimination of behavior problems. 2. Ask students for examples of "great and desperate cures" they know of - from either the past or present. 47 Behavior Session 1 3. Present the first part of "Joey's Story, " using overhead 24. Just like our interest (obsession..) in finding a miracle diet can cause us to ignore real problems such as over eating, lack of exercise, etc. the use of a "BEHAVIOR PLAN APPROACH" to supporting people with severe behavior challenges helps us ignore real issues in the person's life that need our attention. Look at the story below. JOEY'S STORY Joey was ten years old. He went to school in a class designated for students with mental retardation and "SEVERE BEHAVIOR DISTURBANCES." Joey, like the other boys and girls in the class, was often involved in hitting, kicking and crying. In addition, Joey usually did not follow the instructions of the teacher - because of this behavior he had been labeled by the school psychologist as "EXTREMELY NON-COMPLIANT." Joey was sent to a university diagnostic center for further evaluation. The evaluators agreed that he was indeed "NON-COMPLIANT" and recommended the behavior plan that follows. 48 Behavior Session 1 NON-COMPLIANCE TRAINING PROGRAM 1. Joey's parents and school staff begin a compliance training program as a first step in establishing control over his behavior. This program involves: A. 3 - 4 training sessions lasting about 10 minutes should be conducted daily. During these sessions specific tasks that you know Joey can do should be presented. The meaningfulness of the tasks is secondary to requiring compliance to demands of the task situation. B. When Joey first attempts to run away or tantrum he should be immediately brought back to the on-going task and required to comply. Physical prompts and manual guidance may be used to guide him through the task. A new activity should not be introduced until he has complied with the original task. Reinforcement should not be given until the entire task is completed. 2. A time out program should be implemented in order to reduce his aggressive and non-compliant behaviors. His self-injurious behavior should be ignored. If he becomes aggressive or repeatedly refuses to comply to demands, he should be escorted to the time out room and be required to remain in the room for a minimum of 10 minutes. 3. He should receive frequent reinforcement for his positive social behaviors and interactions. 49 Behavior Session 1 Their plan was based on the assumption that the only problem to be solved was Joey's BEHAYIOR (not following instructions and refusing to behave himself) and that the solution could be as simple as the implementation of a behavior plan. The evaluators believed that the school staff could "FIX" Joey (teach him to be compliant) in only 30-40 minutes of training each day. There was no need to need to change anything else - just implement the behavior plan (diet) and his problem would be solved. Similar to the way special diets ignore the principles of good nutrition this type of limited behavior plan ignores the fundamentals of good teaching. The members of Joey's evaluation team apparently did not attempt to answer any of the following questions: Does Joey trust his teacher, feel safe in the classroom Does Joey enjoy any of his classroom activities? Does Joey get to choose his assigned activities? Are the assigned too boring? Are tasks too challenging? Behavior Session 1 Does Joey know how to say "No" in any other way than by being aggressive or disruptive? Would Joey's teacher honor his saying "No" if he weren't aggressive? There are of course many more questions we would ask if we were making a serious attempt to understand why Joey behaves the way he does and to then develop a teaching plan that calls for changing all the relevant factors. We would base our plan on an understanding that: 1. we (the system) are the ones who will have to change the MOST. 2. We will have to change FIRST, if Joey is to be helped, We would understand that much about the classroom environment may need to change, not just Joey's behavior. After deciding not to implement the behavior plan the school staff spent time in Joe~s class, trying to get an over-all picture and not just focusing on his "NON-COMPLIANT" behavior, His parents and staff asked questions such as: What does Joey like to do? What does Joey do well? What real choices does Joey have? What mistakes have we made in the past? Are we repeating them now? 4. Present the rest of "Joey's Story." Behavior Session 1 WHAT THEY FOUND WAS INTERESTING. FOR EXAMPLE: Joey's teacher admitted that in her opinion, "Joey did not like any of the tasks he was assigned in the classroom." He did enjoy recess and music class, but had been excluded from both because of his disruptive behavior. Joey's teacher said she allowed him to choose most of his educational assignments. However, she admitted that the only real choices presented to Joey were to: (1) Do something he did not want when asked by the teacher. (2) Refuse the teacher's request. The teacher aide almost never ASKED Joey to do things. He usually TOLD him what to do, in a very demanding tone of voice. Mike, the student who sat next to Joey, had frequent temper tantrums and also often refused to follow the teacher's instructions. Mike's tantrums seemed to keep Joey on edge and it seemed like he might be imitating some of Mike's more aggressive behavior. Behavior Session 1 BASED ON THESE OBSERVATIONS THE SCHOOL STAFF MADE A NUMBER OF CHANGES IN THEIR TEACHING AND SUPPORT PROCEDURES. FOR EXAMPLE: It was not possible, at that time, to move Joey to a class where he could spend more time with students who would serve as better role models. However, they were able to arrange for Joey to spend more time in other classroom settings - especially gym class and music. It took extra staff to make these arrangements work, but they showed the school administrators that they had already been using extra staff to intervene in crises created by Joey's aggressive behavior. The teacher arranged for a few new classroom activities, based on choices made by Joey. The activities weren't clearly "EDUCATIONAL" but staff figured that once Joey was happier about being in class they could gradually introduce more educationally oriented activities. The aide tried to be more supportive and made less demands on Joey. He learned to ask rather than command. Behavior Session 1 Now of course these and the other changes implemented by the staff did not result in immediate, dramatic changes in Joey's behavior, but then neither would the compliance training behavior plan. The staff came to see that there would be no quick solutions, no "GREAT ANUl DESPERATE CURE" for Joey. They also understood that Joey needed to change too. They knew that if Joey could learn to follow instructions more consistently, to complete tasks that were not always the most interesting thing to him, that they and Joey would be better off. They knew they needed to help him learn to deal with delays in getting what he wanted, to handle frustration without being so disruptive. With this in mind they also implemented a new teaching program that focused on helping Joey learn alternatives to disruptive and dangerous behavior when he was frustrated or angry. The teacher showed Joey how to raise his hand and ask for help instead of yelling. . Behavior Session 1 Given Joey's difficulties in learning new skills his teacher knew that just demonstrating appropriate behavior and waiting for Joey to behave himself would not be enough so; 1. He had other students model the appropriate behavior. 2. He shaped Joey's behavior by at first enthusiastically rewarding any behaviors he showed in frustrating situations that were less disruptive or aggressive. 3. He rewarded Joey for following directions and completing tasks by allowing him to shift to preferred activities rather than by giving him even more work to do. The staff realized that this would take some time to accomplish and would require everyone that worked with Joey to be supportive. Looking back at the initial compliance training plan they wondered how any of them could have believed that 10 minute training sessions to "FORCE" compliance could have ever been successful. Even worse, what if they had implemented the Plan and Joey had eventually been forced to comply? Now understanding how far they had been from meeting Joey's needs, would that really have been a success? Session 1 Behavior Videotape: "An Elephant at Mouse Place" Format Videotape/discussion Time 30 minutes Materials "An Elephant at Mouse Place" videotape Videotape player 57 Behavior Session 1 Objectives Upon completion of this section, students should be able to: 3.1 Recognize that it can be difficult to support people with challenging behavior because most community- based programs were not designed to meet their needs. 3.2 Understand that most challenging behavior makes sense, from the point of view of the person engaged in it, especially when you realize how far our services are from meeting the needs of the person with challenging behavior. Notes 1. Briefly introduce the videotape. 2. Show the videotape. 3. Conduct a discussion of the videotape, reinforcing the points made in the video. 60 Ralph's Story Behavior Session 1 Format Lecture Time 30 minutes Materials Overheads 25- 29 Handout 4- Ralph's Story Behavior Session 1 Objectives Upon completion of this section, students should be able to: 3.1 Recognize that it can be difficult to support people with challenging behavior because most community- based programs were not designed to meet their needs. 3.2 Understand that most challenging behavior makes sense, from the point of view of the person engaged in it, especially when you realize how far our services are from meeting the needs of the person with challenging behavior. 62 Behavior Session 1 Section F: Content Even though this is Ralph's story, fmt you need to learn about a fellow named Leroy. LEROY Leroy is 38 years old, about 6'2" and weighs about 195 lbs. He enjoys wearing sleeveless T-shirts, denim overalls and big, black army boots. Leroy has been labeled as moderately retarded and also having schizophrenia. People who know Leroy well are not sure about these labels, but it is clear that he finds it very difficult to learn new tasks, has great difficulty expressing himself and does, at least at times, seem to be confused by voices that he hears "in his head." The people in Leroy's life all agree that they have a very difficult time getting along with him. While at times Leroy shows a good sense of humor and can be cooperative, most of the time he fails to complete his work assignments, refuses to follow simple directions, often picks on and steals from other clients and has already injured two staff at the workshop and one at his group home. There are times when staff feel that they must hold him to protect him or someone else - it takes three or four of the strongest staff to hold him safely. Notes 1. Present "Ralph's Story," using overheads 25- 29. Behavior Session 1 Looking closer at the workshop Leroy attends might give you a better understanding of his situation. Leroy attends the Ajax Industrial Center because: 1. Its catchment area includes the ICF/MR residential program he recently moved to. 2. His vocational rehabilitation worker decided that he was not appropriate for their services because of his disruptive behavior. 3. It was the only program that would accept him. Even though everyone agreed that his skills and past work history clearly indicated that, in most ways he fit their criteria for the competitive or supported work program, the team decided that he should be placed in the work adjustment program. At this workshop, individuals are placed in the work adjustment program if they are considered not to be "READY" for more advanced programs either due to skill deficits, or as in the case of Leroy, because of "SEVERE BEHAWOR PROBLEMS." There are seven other clients in Leroy's group supervised by two staff. Leroy spends most of the day assigned to "WORK" tasks that are similar to the contracts that he may some day "GRADUATIZ to. However, both Leroy and his supervisors know that he does not do real work. In fact, the items that Leroy packages are unpacked by a woman working at another table in he work adjustment area. He then has the task of putting them back in the boxes again. 64 Behavior Session 1 What happened yesterday is a good example of the problems that occur at the workshop. When Leroy first sat down at his table in the work adjustment room the supervisor told him he would be working on a new job. The workshop had obtained a new contract, and he wanted Leroy to learn to complete one of the assembly tasks required in the contract work. The supervisor placed a pile of bolts, nuts, washers and bags in front of Leroy. From the beginning, it was clear that Leroy did not need to "LEARN" the task. He quickly assembled three bolts and placed them appropriately in the parts bag. The real question,was not whether Leroy could learn to do the task - he already knew how - but rather whether he would do what he was told, when he was told, without being disruptive or hurting himself or anyone else. Leroy worked steadily for about 15 minutes, then he began to ask for a break. The behavior plan developed for Leroy classifies his requests for breaks as inappropriate avoidance behavior and calls for the staff to ignore him and if necessary, redirect him back to the task. The staff member followed the plan and simply ignored Leroy's repeated requests to "take a break," "get a cup of coffee," "go to the bathroom." Leroy's requests had no visible effect on the supervisor, although he did praise him the few times he did return to work. After about 15 minutes of having his break requests ignored, Leroy said, "I'm quitting . . . you can't make me work," and shoved his chair back from the table. He sat there glaring at his supervisor. The supervisor ignored Leroy for about 10 minutes and then quietly asked him several times to "Please go back to work." The first time Leroy said "No!" later he simply ignored the supervisor. The supervisor was experienced enough to know that it would be a mistake to try to force Leroy's chair back to the table, He knew that it could result in a real fight so he decided to take the work to Leroy. He picked up one of the bolt assemblies, held it in front of Leroy and asked him to please go back to work. At first Leroy ignored him, but after a few minutes he grudgingly completed the bolt assembly. Thinking that it might now work, the supervisor said, "Let's move you back to the table. " Leroy immediately said "No!" The supervisor decided to be a little more assertive and said "Come on Leroy, you know you have to work," as he put his hands on Leroy's chair. Leroy looked up at the supervisor and yelled "No! No! I won't." The supervisor quickly decided that it would be a mistake to back down now and began to gradually drag the chair toward the table. Leroy immediately slammed both his arms to the chair, just missing the supervisor's hands. The supervisor jumped back and said, "OK, we can't make you work - but if you don't work, you won't get paid and you don't get a break." Immediately Leroy began to yell. He threw the bolt, breaking the window in front of his table. Then he began to cry and bite his hand and lips. The supervisor told Leroy to stop. He didn't. The other work adjustment supervisor called for help. It took four of the staff about 40 minutes to calm Leroy down, once they were able to hold him in a safe position on the floor. The staff of the ICF/MR facility were called and after Leroy had calmed down they took him back to the residential facility. Later that day at a special team meeting, Leroy was suspended from the workshop for the rest of the week. The behavior specialist was instructed to develop a more powerful behavior program and be ready to implement it by the time Leroy returned next Monday. Now we can move on to Ralph. Don't forget what we've learned about Leroy. We will come back to him later. RALPH Something is missing at the agency where you work! No matter where you work, whether at a group home, workshop, supported work program, etc. What's missing is an 8x1O color picture of Ralph! Ralph is 24 years old, about 5'4" and weighs in at about 155 lbs. He takes great pride in his appearance - button down collars, pressed pants - much better dressed than most of us. Ralph has Down Syndrome which makes it harder for him to learn, limits his ability to generalize what he has learned to new situations and has resulted in him being much shorter than he would like - he plays a lot of basketball. Ralph is very good natured -he smiles a lot and is very easy going. You might even say that he is "OVER" compliant. As a matter of fact you could walk up to Ralph at the workshop and ask him to run around the room four times in a row. He probably would do it - without a question - even if he had never met you before. You never have a problem with Ralph. He may not be the fastest worker at the shop, but he is reliable and very seldom complains. You may be wondering why you need a picture of Ralph for the lobby of your workshop or above me fireplace at home. Sure Ralph is a nice guy, maybe especially nice, but so are many people. Why his picture? The answer is simple - you should hang a picture of Ralph somewhere in the program, especially in a place you have to walk past every day to remind you, and everyone else that works with you that - "The Program Was Designed for Ralph!" Of course, the people who actually designed the facility and program you work in did not know the fellow named Ralph in this story, but they must have had people like him in mind when they made many of their important planning decisions. How do I know they designed the program for Ralph, or at least for fellows like Ralph? Of course I've never even seen your program but I bet the following description is more true than not. 68 Behavior Session 1 Most Community-Based Service Programs: Program Program History Options : Staff Training 69 Behavior Session 1 70 MOST COMMUNITY-BASED SERVICE PROGRAMS: PROGRAM HISTORY: Years ago, when the program began most of the individuals had only mild or moderate disabilities. Over the years the program has begun to accept persons with more severe disabilities but still has only limited experience with persons who have severely disruptive, possible dangerous behavior. STAFF RATIOS: Most of the staff supervisors in day programs are responsible for 12 - 15 maybe even 20 employees. The ratios are better in most residential programs, one to three at best, to one to eight in some larger programs. However, it is usually more difficult to provide close supervision in home settings. STAFF TRAINING: While there may be a basic inservice orientation program, few of the staff have had intensive training and guided supervision in teaching persons who have great difficulty in learning and communication, especially those with severely disruptive behavior. PROGRAM OPTIONS: Many of the individuals were placed in their particular day or residential program because it was the best one available, sometimes the only one available. Teams try hard to make the program fit the individual but far too often it is the other way around. Behavior Session 1 INDIVIDUAL CHOICES: Most teams encourage client decision making. Some individuals even have "INCREASED DECISION MAKING" as an objective in their service plan. In reality however, most of the big decisions such as program placement, work assignments, selection of housemates, daily and weekly activity schedules, what food is purchased at the store, etc. are made by people other than the individual. RULES/REGULATIONS: The agency has a policy in i~ by-laws that states, "Persons who are a danger to themselves or others must be expelled from the program." You are probably starting to get the picture. The program planners must have had Ralph in mind when they developed the budget, determined staffing patterns, etc. Luckily, most of the time it works for fellows like Ralph. But guess what? "We Designed the Program for Ralph" and then Leroy showed up! Leroy must feel like the tourist from Georgia who expected to get to Mexico City on a big, modern, air conditioned bus. When the bus arrived he found that it was small, old, not air conditioned (except for the hole in the rooo and was routed to Mexico City via Saint Paul, Minnesota. The tourist was even further surprised when he complained to the staff of the bus line and was told to: "BE QUIET," "STOP COMPLAINING," "LOOK AROUND, NO ONE ELSE IS MAKING A FUSS." Of course, that's not how most bus lines operate - they would go out of business. When a business makes a promise to meet our individual needs and then doesn't, we expect our money back, or at the least, an apology. However, far too often human service programs operate like the bus line in this story. We operate under federal and state laws that are supposed to guarantee people with disabilities that they will receive an individualized program based on what they actually need rather than simply what is available, in the least restrictive setting, etc., etc. Behavior Session 1 Most of the time programs make very sincere attempts to make good on these promises. Too often however, funding shortages, rules imposed by others that we camot change, the complexity of the needs of those we seine all make it impossible to do what we know we need to. It is nothing to be ashamed of, unless we know of improvements that could be made but are being ignored. It is also true that, even with such major limitations our programs often are helpful - especially for people like Ralph, Leroy has not learned to play the role so often demanded of people with intellectual disabilities. People with mental retardation often learn that their life is less disruptive if they say "YES"; do what they are told, rather than voice their own opinion; learn to please others rather than themselves. There is a good side to this of course. We all know that it is necessary to learn to compromise, to do things or follow instructions that don't always please us, etc. It is also clear that Leroy's life, and ours, will be more calm and less dangerous if he can learn to be a little more like Ralph. The important question is how can we support him in learning more adaptive and less dangerous ways of voicing his criticisms. Behavior Session 1 Ralph's Story Exercise Format Individual/small group exercise Time 80 minutes Materials Worksheet 2 - Ralph's Story In-class Exercise Worksheet 3 - Ralph's Story program 75 Behavior Session 1 Objectives Upon completion of this section, students should be able to: 3.3 Increase their skills in advocating for people with challenging behavior by giving them experience in: Figuring out why people engage in challenging behavior. Explaining to others why people engage in challenging behavior. 76 Behavior Session 1 Section G: Content RALPH'S STORY IN-CLASS EXERCISE YOU COULD LOOK AT FACTORS SUCH AS: Have there been inconsistencies in staffing, scheduling that are difficult for the person to understand and accept? Are there situations that we know the person has a difficult time dealing with such as crowds, loud noises etc. but are still a part of her/his everyday life? How much choice does the person have over who they live or work with? Does he/she have any real friends? Especially friends who advocate on behalf of the persorip How well do we do at communicating with the person? How well do we understand the person's attempts to communicate? How much of the person's program really reflects his/her individual needs? Notes Use the worksheet 2: "Ralph's Story In-class Exercise" and conduct the following exercise based on the structure and makeup of the class. When the course is a one-day class: 1. If the students all work together, divide them into groups of two or three; otherwise, have individuals complete the exercise. (5 minutes.) 2. Have the small groups or individuals go through the practicum exercise for at least one person that they know. Allow about 20 minutes for this step. 77 Behavior Session 1 3. When each individual\group has completed the form, have individuals/groups describe their person and the conclusions they came to as they completed the exercise. Comment as appropriate to encourage students to expand their views of people with disabilities and the possible reasons for the behavior problems. Allow about 5 minutes per person or a maximum of 40 to 50 minutes for this step. 4. Take about 5 minutes to summarize some of the most important points brought out by the students. IMPORTANT: From the person's point of view, from his/her own experience, does the challenging behavior work? Does it help the person GAIN what they want? ESCAPE from or avoid what they do not want or like? MOST IMPORTANT: Does the person really have any other options or choices that also work, or, is her/his situation similar to Leroy's? Leroy didn't know of some of the options that might have been available to him. He might have been able to complain to his case xpanager or his legal rights representative but he didn't know he could. However, he did know that saying he didn't want to work, even asking repeatedly to stop, DID NOT WORK. From his point of view disruptive and aggressive behavior worked almost every time. We might be able to see that his aggressive behavior also caused Leroy lots of problems, but when you have no other alternatives you go with your experience and usually continue with what has worked most of the time. 78 Behavior Session 1 AS YOU THINK ABOUT WHAT YOU ARE GOING TO SAY, KEEP THE FOLLOWING POINTS IN MIND: a. Please talk for the person. In other words, use first person statements. Use language like: "I sometimes do the following things ......," "The reasons I often bite my hand are . . . . . . . This may seem awkward at first, we are all more used to talking like: "The client's challenging behaviors are . . . . . or "The learner has behavioral diffkulties because of the following ..." but it is very important that you present the person's case as exactly as you think they would, if they could. b. Don't worry about coming up with solutions or answers as to how to deal with the challenging behaviors yet. In this exercise we are simply trying to improve our understanding of the causes or reasons for challenging behavior. Don't let anyone convince you that your understanding must be wrong simply because you don't have a ready solution to the problem. c. This is not a debate and there are no obvious right or wrong answers. 5. Hand out Worksheet 3 of the at - home version of "Ralph's story practicum" exercise and encourage students to go through the exercise again with an individual, this time using additional information about the individual. If the course is divided into two sessions: 1. Hand out Worksheet 3 of the at-home version of the practicum exercise and explain exactly how the students are to perform the exercise before the next session. Point out that they will be sharing their conclusions at the next session. 2. At the beginning of the second session, go through steps 3 and 4 above. 79 Behavior Session 1 Note: If the students are not likely to complete this exercise between classes, then be sure to fit the exercise into the class itself. It can also be done a second time by those students who are willing to take the time between classes. If the class consists of those who do not yet work with individuals with disabilities: Go through the same exercise, but instead of having students use someone they know and work with, prepare case studies, similar to the "stories" presented in curriculum, and have students use that information for the exercise. IMPORTANT: Keep in mind, we are not trying to condone or apologize for the person's disruptive or aggressive behavior. We are simply trying to understand why the person engages in the challenging behavior. To say "I understand why Leroy acts so disruptive and sometimes dangerous" is not the same as saying "I accept his behavior - its O.K. for him to hurt others." Listening to, understanding and in a sense respecting the person's reasons for his/her behavior, is the first step toward helping the person make more adaptive, less dangerous choices. 80 Summary and Closing Behavior Session 1 Format Lecture Time 10 minutes Materials Student handouts and worksheets for Session 1 Copies of overheads used in Session 1 Notes 1. Review the main points presented in this session. 2. Give students handouts from this session, including copies of overheads and worksheets. Behavior Session 1 Section H: Content This section has been developed to bring the first half of the session to a close with a review of the material covered in the previous sections. 82 Behavior Session 2 Format Lecture Time 10 minutes Materials Overhead 1 85 Notes 1. Display overhead 1 and review the main points presented in Session 1. 2. Using overhead 1, briefly explain what Session 2 will include. Behavior Session 2 Summary af Ralph's Story Exercise Behavior Session 2 Format Large-group discussion Time 6O minutes if exercise was completed between sessions 15 minutes to su mmarize points if there was no break between sessions Materials Worksheets 2 - 3 87 Behavior Notes 1. If the exercise was completed in class, at this point, simply review some of the main points. If the exercise was completed between sessions, at this point, have students share their conclusions as explained in Session 1, section G. Session 2 Objectives Upon completion of this section, students should be able to: 3.3 Increase their skills in advocating for people with challenging behavior by giving them experience in: Figuring out why people engage in challenging behavior. Explaining to others why people engage in challenging behavior. Understanding Behavior Challenges Behavior Session 2 Format Lecture/discussion Time 35 minutes Materials Overheads 30- 34 Handout 5- Understanding Behavior Challenges 89 Objectives Upon completion of this section, students should be able to: 4.1 Recognize that there are always reasons for why people do what they do; there are causes for challenging behavior. 4.2 Understand that the first step to helping decrease behavior challenges is to understand the cause(s) for the behavior. 4.3 Understand that while there are physical causes for challenging behavior, they are rarely the cause for the challenging behavior. 4.4 Describe the major environmental causes for challenging behavior, through the use of the "VICIOUS CYCLE DIAGRAM. " 4.5 Differentiate between environmental influences that precede (antecedents) versus follow (consequences) the behavior. 4.6 Understand that most challenging behavior is learned and that "WE" are the ones who teach it. 4.7 Look at the situation from the person's point of view, "LISTEN TO" the person's challenging behavior and understand what the person is trying to communicate. 90 Behavior Session 2 Section Content This lesson begins with the following fundamental assumption: THERE ARE ALWAYS REASONS FOR WHY PEOPLE BEHAVE THE WAY THEY DO. It is true that we cannot always identify the reasons or causes for a person's behavior. As you will see in this lesson the causes for behavior can be very complex and difficult to understand. However, we must begin with the working assumption that there are reasons and that if we ask the right questions we will be able to discover them and use our understanding to help the person. CAUSES FOR PROBLEM BEHAVIOR There are many different reasons why a person might be engaging in challenging behavior. For example there may be physical causes for the person's problem behavior. These conditions can be genetic as in the case of Tay Sach's Disease* or acquired later in life such as in the case of brain injuries. However, while there are examples of physical conditions which are directly related to severe behavior challenges such examples are not common and are not likely to be the cause of many of the behavior challenges you encounter. Tay Sach's Disease - a genetic condition that usually results in severe self-injurious behavior. Notes 1. Ask the students to think of someone they know (preferably one of their clients) who "misbehaves. " Then have them suggest reasons why that person might be "misbehaving"- reasons deeper than the obvious. 2. Using overheads 30--34, present the content on "Understanding Behavior Challenges." Behavior Session 2 PHYSICAL CAUSES Even though physical conditions rarely account for why the person is engaging in challenging behavior they should always be checked out. There are many examples of persons engaging in self-injury such as head banging because of ear infections, chronic headaches, impacted ear canals, dental problems, temporal lobe seizures etc. Especially if a person shows a dramatic and rapid change in behavior, it usually makes sense to carefully examine whether there could be a physical cause for the behavior. ENVIRONMENTAL CAUSES Most of what we know about human behavior clearly supports the notion that our behavior is strongly influenced by our environment, especially our LEARNING EXPERIENCES. A careful examination of the VICIOUS CYCLE chart may help in your understanding of how our environment and past learning experiences effect behavior. FACTORS THAT PRECEDE THE BEHAVIOR Common sense tells us that there are many things that make us happy, bored, confused, interested, angry, depressed, satisfied, etc. We are clearly not all the same - what bores me may interest you, what makes you mad I may think is funny. For people with disabilities the situation is often even more complicated. Behavior Session 2 For example, many people with autism are extremely sensitive to differences in touch, taste and noise. Read the following quotes from Temple Grandin, a person with autism. "Like birthday parties. They were torture for me. The confusion created by the noise makers suddenly going off startled me. I would invariably react by hitting another child or by picking up an ashtray or anything else that was handy and flinging it across the room. " "Even today, sudden loud noises such as a car backfiring, will make me jump and a panicky feeling overwhelms me, Loud, high- pitched noises such as a motorcycle's sound, are still painful to me. " Often it may not be just one thing, it may be a combination of many different environmental factors. See another quote from Ms. Grandin: "But as a child, the `people world' was often too stimulating to my senses. Ordinary days with a change in schedule or unexpected events threw me into a frenzy, but Thanksgiving or Christmas was even worse. At those times our house bulged with relatives. The clamor of many voices, then different smells - p,erfume, cigars, damp wool caps or gloves - people moving about at different speeds, going in different directions, the constant noise and confusion, the constant touching, were overwhelming." Behavior Session 2 WE REACT, IN PART, BASED ON HOW WE FEEL It's not surprising that when people feel frightened, angry or in pain, they often behave in ways that are disruptive and even sometimes dangerous. Our experience tells us that when people are bored or confused their behavior often becomes more erratic and less predictable. So far this would not present much of a problem. The real trouble begins in the next phase of the process. WE DISCOVER THAT DISRUPTIVE EVEN AGGRESSIVE BEHAVIOR OFTEN "WORKS" This is when the role of learning begins to play a powerful role in shaping our behavior. We all learn from our experiences and tend to repeat those actions that work for us. Behaviors that work are strengthened (rewarded/reinforced) and those that don't or result in pain or discomfort are weakened and eventually eliminated. The consequences or results of our behavior are very important in determining our future actions. EVEN THOUGH THE DISRUPTIVE BEHAVIOR OFTEN "WORKS," ON A SHORT-TERM BASIS IN THE LONG RUN MORE PROBLEMS ARE CREATED Aliemtion, exclusion from programs, etc. This usually increases the discomfort and confusion in the person's life, which results in even more disruptive behavior. This `VICIOUS" cycle is clearly evident in the lives of many people with challenging behavior. Behavior Session 2 We can see an example of this TYPE OF CYCLE in the story of Leroy, from one of the earlier lessons. Remember the day that Leroy was assigned a new task? Let's look at that situation from the point of view of how Leroy's behavior worked, or did not work for him. Leroy worked steadily for about 15 minutes, then he began to ask for a break. The behavior plan developed for Leroy classified his requests for breaks as inappropriate avoidance behavior and called for the staff to ignore him and if necessary, redirect him back to the task. His supervisor followed the plan and consistently ignored Leroy's repeated requests to "take a break," "get a cup of coffee," "go to the bathroom." Leroy's requests had no visible effect on the supervisor. However, he did praise Leroy the few times he returned to work. Is it unreasonable that Leroy would rather take a break than assemble nuts and bolts that someone else is simply going to take apart? The few dollars a week that he earned at this task were not sufficient to make it any more interesting. It's worth noting that it is also not all that unreasonable, at least from a staff point-of-view, that Leroy's supemisor wanted him to complete the packaging tasks. There was an objective related to work on Leroy's 1P and if he did well he thought Leroy might be able to "graduate" from the work adjustment program and join the other employees on the workshop floor. The supervisor would probably say that he is trying to teach Leroy to "work consistently" by praising him and that by ignoring Leroy's complaining and asking for frequent breaks he will learn that such behavior is inappropriate. Leroy might tell a different story! He might say that he is learning that "it does not help to ask to stop work," He might say that "no one listens to me" and that he has no role in decision making at the workshop. After about 15 minutes of having his requests for a break ignored, Leroy said "I'm quitting . . . you can't make me work" and shoved his chair back from the table. He sat there glaring at his supervisor. The supervisor ignored Leroy for about 10 minutes and then quietly asked him several times to "Please go back to work." The first time Leroy said "No!," after that he simply ignored the supervisor. From Leroy's point of view he had finally found something that worked. If the supervisor wouldn't let him have a break he would just go ahead and take matters into his own hands. Is it surprising that he refuses the supervisor's requests to return to work? What has he got to gain, other than a little praise and probably more work? The supervisor was experienced enough to know that it would be a mistake to try to force Leroy's chair back to the table, He knew that it could result in a big fight so he decided to take the work to Leroy. He picked up one of the bolt assemblies, held it in front of Leroy and asked him to please go back to work. At first Leroy ignored him, but after a few minutes he grudgingly completed the bolt assembly. Thinking that it might now work, the supervisor said, "Let's move you back to the table." Leroy immediately said "No!" It was probably a very wise decision for the supervisor to decide not to force the issue with Leroy by attempting to immediately drag his chair back to the table. He waited till Leroy calmed down a little and then "took the work to him." He wanted to teach Leroy, as gently as possible, that he could not avoid work by moving away from the table. It's not clear why, but Leroy cooperated, at least at first. Did Leroy's cooperating work, from his point of view? Not really. The supervisor said "Good working Leroy" but then proceeded to try to get him to move back to the table. Leroy's cooperative behavior led to more requests to return to work. Not such a good deal from his point of view. The supervisor decided to be a little more assertive and said "Come on Leroy, you know you have to work," as he put his hands on Leroy's chair. Leroy looked up at the supervisor and yelled `No! No! I won't." Leroy has learned his lesson - no more cooperation. He continued to say NO!, even louder. The supervisor quickly decided that it would be a mistake to back down now and began to gradually drag the chair toward the table. Leroy immediately slammed both his arms to the chair, just missing the supervisor's hands. The supervisor jumped back and said, "OK, we can't make you work, but if you don't work, you won't get paid and you don't get a break." Leroy finally found a "SIGN" that worked and worked quickly, one that the supervisor clearly understood. He might have been a little confused about why he had to yell so loud and slam his arms repeatedly on the chair just to be heard but if that's what it took to get through to the supervisor then he would just have to do it. Now, I don't really believe that Leroy thought all these things, but I do believe that the above is a fair description of what he was being taught by the supervisor. He was learning that cooperation and task completion usually lead to more task assignments. He was learning that simple verbal complaints or requests for breaks had no effect. He learned very concretely that disruptive, aggressive behavior got him what he wanted. From Leroy's point of view it was the only way he could get what he wanted. Immediately Leroy began to yell. He threw the bolt, breaking the window in front of his table. Then he began to cry and bite his hand and lips. The supervisor told Leroy to stop. He didn't. The other work adjustment supervisor called for help. It took four of the staff about 40 minutes to calm Leroy down, once they were able to hold him in a safe position on the floor. The staff of the ICF/MR facility were called and after Leroy had calmed down they took him back to the residential facility. LEROY'S SUPERVISOR MADE A SERIOUS MISTAKE. HIS "MESSAGE" TO LEROY WAS: "YOU MUST WORK" "I WILL IGNORE YOUR EFFORTS TO AVOID OR ESCAPE WORK" "THE ONLY THING THAT WORKS AROUND HERE IS TO DO WHAT I SAY" Leroy did in fact discover that simply asking to quit didn't work. He found out that minimal efforts to escape or avoid work, like moving away from the table, also didn't work. But Leroy has a long history that says to him: "ESCALATE" "STMT YELLING" "THROW THINGS" "BITE YOUR HAND" "HIT SOMEONE" These behaviors have always worked. In the long run, which Leroy does not understand or care much about, these behaviors also have had a serious negative impact on his life. He has been restrained, placed in seclusion, expelled from programs and even institutionalized because of them. These behaviors have been labeled as inappropriate, maladaptive, abnormal, even crazy. However, to Leroy they work in the short term and that is all that he understands now. Unless we make some important changes, the situation usually gets even worse. Leroy continues to hit his supemisor and the supervisor, in turn, continues to restrain Leroy. Quite naturally what little positive working relationship they did have is diminished. The supervisor pays less and less attention to Leroy unless of course he is being disruptive. Leroy is even less likely to have any positive experiences at work, which in turn makes it more likely that he will try to quit or leave. Over time he is less likely to even try the non-aggressive ways of quitting - such as asking for a break, simply trying to walk away, etc. - these have never worked. Leroy learns to skip these steps and move directly to what does work - dangerous and disruptive behavior. You may be thinking that you would not find it rewarding to be restrained, to be expelled from a program. Please do not' judge the situation from your point of view. You must learn to look at what is happening from Leroy's point of view. 102 Behavior Session 2 That is not the same thing as saying that Leroy's behavior is "CORRECT" or "RIGHT." It simply means that if we are to understand why Leroy does what he does, we must understand his point of view. What we think of as "NEGATIVE ATTENTION" may in fact be rewarding to people with long histories of challenging behavior. For example it is probably true that criticism, negative feedback, being yelled at, etc. is punishing to most people. Whether it is true for most people is not the issue here. Leroy's point of view is all that should be considered if we are to understand him. LOOK AT THE SITUATION THROUGH HIS EYES: Leroy does not have a positive working relationship with anyone at the workshop. why should he care whether they are pleased with his behavior? why should he change his behavior based on their criticism? If Leroy behaves himself, follows instructions, does not cause trouble, etc., he will probably be ignored. At times he may be praised for his appropriate behavior, but that is nothing compared to the immediate attention provided by the "crisis team" when he is disruptive. He becomes the center of attention, for the entire workshop. 103 Behavior Session 2 IMPLICATIONS FOR CHANGE IN OUR SERVICES Look back at the "VICIOUS CYCLE" diagram. It is clear that based on the understanding of the cause(s) for behavior problems shown in the diagram that we can consider making changes in at least two major areas, if we are to help the person change his/her behavior. First, we can try to decrease the person's exposure to situations that are confusing frustrating, boring, frightening, etc. Second, we can assist them in learning alternative behaviors that also work for them, but that are not disruptive, dangerous or confusing. Behavior Session 2 Understanding Reasons for Behavior Format Small - group activity Time 30 minutes Materials None Session 2 107 Behavior Session 2 Objectives Upon completion of this section, students should be able to: 4.1 Recognize that there are always reasons for why people do what they do; there are causes for challenging behavior. 4.2 Understand that the first step to helping decrease behavior challenges is to understand the cause(s) for the behavior. 4.7 Look at the situation from the person's point of view, "listen to" the person's challenging behavior and understand what the person is trying to communicate. Behavior Session 2 Notes 1. Ask students to think of a task or activity that they are required to perform but that they really hate doing. Ask several to state the task or activity they selected. 2. Pick a volunteer (a student who can easily act the role). Have the student "act out" with you (the instructor) the following scenario: The instructor tells the student to perform the despised activity. The student must communicate to the teacher that he/she does not want to perform the activity, but the student may not communicate verbally at all - either through speech or writing. The instructor's job is to totally misinterpret the student's signals. This role-playing should take only a few minutes. 3. Have the student who performed the role play tell the class how he/she felt about not being understood. Explain that the feelings are similar to those felt by persons with developmental disabilities who are unable to communicate what's going on for them. 4. Divide the class into groups of two and have each pair perform the activity described in step 2. Have each person act out both the person trying to communicate and the one not understanding the communication, as explained above. 5. When both partners have performed both roles, they should take a few minutes to share their experiences with the other, particularly how it felt to be misunderstood. 6. Finally, ask a couple of students to share their experiences with the whole group. 109 Behavior Session 2 Supporting Learning vs. Managing Behavior Format Lecture/discussion Time 45 - 55 minutes Materials Overheads 35-47 Handouts 6 - 7 Carl, Merle, Mary and the Angry Bus Driver Kathy's Story - Success Is In the Eye of the Beholder Behavior Session 2 Objectives Upon completion of this section, students should be able to: 5.1 Discriminate between simply managing a person's behavior, usually to decrease problem behavior versus supporting the person in learning more appropriate behaviors. 5.2 Recognize that they should always begin by attempting to support the person in learning more appropriate behaviors by changing services to better meet the needs of the person and teach alternative behaviors. 5.3 Determine that often the major "PROBLEM" they should deal with is not the challenging behavior of the person; rather it is the fact that the person has been provided services which are not individualized and do not meet his/her needs. Behavior Session 2 Session E: Content CARL, MERLE, MARY AND THE ANGRY BUS DRIVER Carl works in a group home. Mary, who is Carl's supervisor was very concerned about his work performance. One of Carl's most important job responsibilities is to help the men who live in the home in preparing to go to work each morning. Carl works well with two of the men. They are ready for work on time each day. The third man, Merle is a different matter. At least once a week Merle is still eating breakfast and not even completely dressed when the bus comes. Mary has talked to Carl about this often, each time emphasizing how important it is for Merle to be ready for work in time to take the bus. The talks don't seem to have helped . . . twice in the last week the bus driver had to wait for Merle and once he was so late Carl had to call a taxi. Mary has developed a new plan that she thinks may work. Today she told Carl that if in the future Merle is late for the bus she will write an incident report and place it in his personnel file. If Carl gets more than one incident report over a two week period he will receive a written reprimand. If he receives more than three reprimands in a month he will be fired. However, if he helps Merle get ready for work on time every day for two weeks in a row she will arrange for him to have special time off from the job. Mary told Carl that she wished that these procedures weren't necessary, but that she felt like she had to implement them. Notes 1. Read the first three paragraphs of "Carl, Merle, Mary, and the Angry Bus Driver." 113 Behavior Session 2 2. Display overhead 35 and ask for responses to the questions posed in the story: What is missing in the above story? DO you agree with Mary's approach to dealing with Carl's "problem" behavior? Spend 10 to 15 minutes discussing these questions. 3. Present the next section of the story, and then review it using overheads 36 and 37. QUESTION: "WHAT IS MISSING IN THIS STORY? " "DO YOU AGREE WITH MARY'S APPROACH TO DEALING WITH CARL'S "PROBLEM" BEHAVIOR?" You might not agree with Mary's choice of a punishment approach to changing Carl's behavior. You might be concerned that the procedures may not work and Merle will continue being late and Carl will be fired. However, there's an even more basic weakness to Mary's approach to dealing with the problem. She never tried to find out why Carl wasn't doing what he was supposed to do. She might have then been able to develop a plan to help Carl succeed, based on this information. 114 Behavior Session 2 TALKING WITH CARL AND OBSERVING THE MORNING ROUTINE MIGHT HAYE SHOWN: That Carl was afraid of Merle and ignored him as much as possible to avoid the possibility of a fight. Because he ignored him, Merle sat around most of the morning without getting ready for work. That Carl was not experienced in helping a person as severely disabled as Merle. He didn't know how to provide Merle with the physical and verbal cues he needed to wash, brush his teeth, get dressed, etc. That one of the other men was taking up most of Carl's time each morning. Although he was working hard; Carl did not have the time to help both men. You are right if you are thinking there could have been many other reasons for Carl not being able to get Merle ready for the bus. However, it's pretty clear Mary's plan had nothing to do with any of them. MARY HAD DEVELOPED A PLAN TO MANAGE CARL'S BEHAVIOR. HER PLAN INVOLVED: Punishing him if Merle was late by putting incident reports in his file which could lead to reprimands and eventually, to being fired. Rewarding him for two weeks of good behavior (Merle not being late) by arranging for time off. Neither of these two consequences have anything directly to do with whatever is causing Carl's failure to help Merle. Mary's plan is based on the assumption that Carls will be afraid of losing his job and will therefore, do whatever is necessary to succeed. It might "WORK," but it has an even better chance of failing. Filing incident reports won't help Carl overcome his fear of Merle. The threat of Iosing his job won't teach Carl how to provide Merle with the types of cues and instructions that he might understand. Mary did not begin by trying to understand why Carl wasn't performing as he should, which would have then allowed her possibly to develop a plan to help him based on what she had learned. You might be thinking that none of the reasons listed above were true and that Carl just needed some extra "MOTIVATION" to do his job. This could be true, but we'll never know without asking the question, WHY? which Mary failed to do. Let's look at a similar situation but this time we will be concerned with the behavior of a person with severe disabilities. Behavior Session 2 KATHY'S STORY - SUCCESS IS IN THE EYE OF THE BEHOLDER Kathy was 9 years old and labeled profoundly retarded. She has been living at a state institution for persons with mental retardation for the last nine months. Each morning one of the aides walked across the grounds to her school program. She was scheduled to stay at school until the early afternoon. Kathy had lots of difficulty adjusting to the school program. During the first few months she often cried and tried to run out of the room. Her teacher, Mr. Richards, handled these situations by ignoring her crying, as much as possible, and gently redirecting her back to her desk if she attempted to run from the classroom. These procedures worked to reduce the crying and running away. During her sixth month at school she only had three tantrums and attempted to run away only once. However, Mr. Richards became concerned about a new behavior that presented even more serious problems. During her seventh month at the Center, Kathy began to vomit while at school. At first it only occurred infrequently but it gradually increased until she was throwing up every day. 4. Present the first part of Kathy's Story, using overheads 38 and 39. Some of the members of her team felt that she might be overly anxious about school and recommended that the physician prescribe a mild tranquilizer. The Doctor agreed with the request but the change in medication did nothing to decrease the vomiting behavior. The team then decided to suspend her from school for a month. This of course worked perfectly to decrease vomiting behavior at school. She couldn't throw up at school unless she was actually there! However, when Kathy returned to school she immediately returned to the vomiting behavior. Hoping to get a new perspective on the situation, the teacher asked the Center's behavior specialist, Roberta Fox to visit the classroom and see if she might be able to help. The first day Roberta visited the classroom Mr. Richards described what had been happening - about the results of the change in medication and the school suspension. As she was finishing the description they heard a sound, looked up and saw Kathy throwing up at her desk. She and the student who sat in front of her were a mess. Mr. Richards immediately called for an aide to escort Kathy back to her cottage to be cleaned up and get a change of clothes. Ms. Fox asked the teacher if what she had just seen was typical of most days. Mr. Richards said yes, that almost every time Kathy threw up she had to be returned to her cottage and that often she did not return to school until the next day. Ms. Fox returned the next day with the following plan for decreasing Kathy's vomiting behavior. Behavior Session 2 At first it looked as though the plan might not work. wthy threw up repeatedly during the first few days. In fact, on the third day she threw up, or at least tried to throw up Z3 times. However, after the third day things began to improve. As the graph shows the frequency of the vomiting steadily decreased over the next 27 days and by the 30th day of the new procedures she went the entire day without vomiting. The graph below shows the frequenw of vomiting over the 30 daY pe~od. she never threw up in class again. Mr. Richards and Roberta Fox had accomplished their objective. Kathy never threw up at school again. Do you consider this a success story? Let's look at the "SUCCESS" of the behavior plan from the point of view of all the people concerned. FREQUENCY OF VOMITING Behavior Session 2 5. Ask students to address the questions: "What about Kathy?" "Why might Kathy be behaving the way she is?" Stop for a 5 tol O minute discussion on these questions. 6. Present the remainder of the story, using overheads 40-46. Mr. Richards - "It certainly was a success. The room smells nicer. Kathy looks better. Now maybe we can get on to school work. " Ms. FOX - "I was more than happy to help Mr. Richards. We eliminated the target behavior faster than I thought we would. Maybe I can publish this as a research study." WHAT ABOUT KATHY?? Kathy cannot talk, but pretend for a minute that she could. How do you think she would answer the success question? Suppose we were to interview her on the 30th dqr of the new behavior plan, the first time she went the whole day without throwing up - what is she going to say? "I JUST LOVE IT HERE!" "MY SCHOOL WORK IS VERY INTERESTING AND I AM LEARNING A LOT." OR "I STILL HATE IT HERE. I'D STILL RATHER LEAW. I JUST DON'T TELL ANYONE ABOUT IT ANYMORE . . . . . Kathy is not likely to answer that the "BEHAVIOR INTERVENTION PLAN" was a success because nothing was done to help her with her "PROBLEM." 720 Behavior Session 2 HER "PROBLEM" WAS THAT EITHER: 1. She disliked/was afraid of the classroom setting 2. Nothing at school was more interesting or engaging than being back in the day room of her ward. The Behavior Plan did nothing to change these "PROBLEMS." The Behavior Plan was just that- a behavior plan. The teacher and Ms. Fox implemented a plan that successful in making an improvement in Kathy's behavior but did-nothing to help the basic reasons behind the problem, behavior. Let's look at the situation more closely. MS. FOX'S ANALYSIS OF THE SITUATION WAS IN A SENSE CORRECX. SHE SAW THAT: Kathy either did not like the classroom or wanted to be back on her ward. Mr. Richards had "accidentally" reinforced the vomiting behavior by letting her leave (escape) the classroom. Over a period of weeks Kathy learned to vomit to leave the classroom. Ignoring the vomiting (not allowing Kathy to leave) would eliminate the "ACCIDENTAL" reward. OVER A THIRTY DAY PERIOD KATHY GAVE UP. SHE STOPPED VOMITING. There is no doubt that if people are placed in situations that they find unacceptable they will try to find a way to leave. They will often do whatever works - tantrums, aggression, even vomiting. There is also no doubt that if you are bigger than they are, if you are in control, you can make sure that nothing works. That's what they did to Kathy. At first Kathy was successful in running from the classroom, but then the teacher learned to beat her to the door. Later she had tantrums and sometimes was sent back to the ward to "CALM DOWN. " The teacher was then instructed to ignore the tantrums. One day while she was having a tantrum she choked and threw up. The teacher immediately said "Take her back to the ward, clean her up. No more school today, she is too upset. " Kathy didn't understand much of what the teacher said but she did learn a new sign: VOMITING - "I WANT TO LEAVE THE CLASS IMMEDIATELY." Behavior Session 2 It wasn't at all clear to Kathy why the teacher required such an unusual sign, why he hadn't understood what IQthy meant by running away and crying both of which seemed to be more obvious to her. But she was happy for small favors and each day followed the teacher's "INSTRUCTIONS" by throwing up when she wanted to leave class. Now of course I don't think that Kathy actually thought all these things out so logically and rationally but at the same time it is an accurate description of the important events and also makes it clear where the focus of our attention should be. We should be most concerned with answering the question - Why does Kathy want to leave the class? There is no arguing with the fact that vomiting behavior is "INAPPROPRIATE" that Kathy would better off if she stopped doing it. In fact, if we really wanted to stop the vomiting quickly it would probably have been more efficient to teach her to exchange a token to leave class. Each day we could give her a blue poker chip. If she hands the chip to the teacher she is immediately allowed to leave the class - no questions asked. In far less that 30 days she would probably have learned the "exchange" value of the token and use it to leave class rather than resorting to vomiting. Behavior Session 2 MANY OF YOU ARE PROBABLY THINKING: "Wait just a minute. Kathy may not be throwing up anymore, but now we have a different `problem. ' She spends very little time in school. Most days she hands in the token after only a few minutes and leaves school." Right! Now we have the "REAL" problem. The one we should have been most concerned with all along, that is, the school setting either frightens/disturbs her or offers her nothing more interesting/fun and engaging than the day room back on the ward. Ms. Fox should have helped Kathy's teacher figure out what was frightening ~thy or how to interest her in at least some activities in the class. That would not have been an easy task. It was difficult to understand Kathy's likes and dislikes, except for the vomiting, and because of her limited experiences and profound disabilities her interests were fairly limited. But the fact is they made only minimal efforts in this direction - they were too focused on eliminating the vomiting behavior. 124 Behavior Session 2 Small - group Exercise for Kathy's Story Format Small - group exercise Time 50 minutes Materials Overhead 47 125 Behavior Session 2 Objectives Upon completion of this section, students should be able to: 5.1 Discriminate between simply managing a person's behavior, usually to decrease problem behavior versus supporting the person in learning more appropriate behaviors. 5.2 Recognize that they should always begin by attempting to support the person in learning more appropriate behaviors by changing services to better meet the needs of the person and teach alternative behaviors. 5.3 Determine that often the major "PROBLEM" they should deal with is not the challenging behavior of the person; rather it is the fact that the person has been provided services which are not individualized and do not meet his/her needs. 126 Behavior Session 2 Section F: Contont GOALS HAVE THE PARTICIPANTS UNDERSTAND THAT: The teacher should have first listened to Kathy and not simply set out to manage her behavior. There were many different ways the teacher could have changed Kathy's school program to deal with whatever was confusing or frightening her. We must learn to define the success of our programs not just in terms of how they meet our (the system's needs) but also the needs of the person with a disability. 1. THE CAUSE(S) FOR KATHY'S VOMITING BEHAVIOR. What about the school setting might be confusing, frightening, boring her. Instruct them to be specific and concrete. 2. THE CHANGES THEY MIGHT MAKE IN THE CLASSROOM BASED ON THESE CAUSES. Notes 1. Divide participants into small groups of three to six people. 2. Display overhead 47 and have students discuss the two items listed. Have someone in each group keep a written list of the potential causes and the changes that might be made. Allow about 10 minutes for this discussion. 127 Behavior Session 2 3. Hove each of the groups report on their discussion. Use the Small Group Discussion overhead (47) to record the findings of the groups as they report. Allow about 20 minutes for this discussion. Ensure that you cover the "general discussion" points listed here. GENERAL DISCUSSION POINTS Participants will probably focus on potential negative features of the school program. They may mention features such as: a. The classroom activities were too boring or too challenging, confusing, frustrating, etc. Ask them to be specific, to describe the specific features that might be causing frustration, boredom, etc. b. The attitude of the teacher. c. The behavior of other students. They may speculate that there is nothing all that bad about the classroom setting and that Kathy would simply rather be back on the ward. Be sure to point out that they were able to list a number of changes that the teacher might have made to make the school program more acceptable to Kathy. Yet, the teacher made only one change - she ignored Kathy's requests to leave. Make sure they understand the importance the contingency between vomiting and leaving the classroom. They may make statements such as: "SHE WAS FRIGHTENED." "THE WORK WAS TOO CHALLENGING." "KATHY WAS TO GO BACK TO THE WARD." Such statements describe only one aspect of the "CAUSE" for the vomiting behavior. Show the participants that the notion that the school work was too boring/challenging COMBINED with the fact that she was able to escape or avoid the work only if she threw up. People don't develop high rates of severely disruptive behavior simply because they have unpleasant feelings. Severely challenging behavior is usually the result of the person learning that unpleasant situations can be quickly improved if he/she resorts to disruptive dangerous behavior. Someone may notice that this was one situation where it was not necessary to teach an acceptable alternative behavior. Kathy knew how to express her desire to leave the room by simply going to the door. She did not resort to more disruptive forms of behavior until this simple form of request was ignored. The issue is not one of teaching IQthy appropriate behavior but deciding where and when we will honor her requests (listen to her). Major Point - It is very difficult to avoid the temptation to describe the problem as "KATHY'S PROBLEM BEHAVIOR" which usually leads to a management intervention that focuses only on the person's challenging behavior. It is more difficult to learn to first ask "what can I do to help?" To work to decrease the motivation for the person to engage in the disruptive behavior by meeting her/his need for support and understanding. It is important to acknowledge that if extensive attempts were made to figure out "WHAT WAS UPSETTING KATHY" and none of the changes helped, the team would have to eventually address the issue of figuring out the least intrusive/aversive way possible to eliminate the vomiting behavior (manage her behavior). This is also true for Carl's situation (described in the written lesson). If Carl's supemisor works with him to make the changes they felt might help him do a better job of working with Merle - and nothing seems to help - she may need to implement disciplinary procedures (attempt to manage his behavior). But only after making a serious attempt to understand his behavior and work to implement supportive changes. 130 Caurse Summary Format Lecture Time 20 minutes Materials Worksheets 4-6 for practicum exercises Handouts for all sections, including copies of Overheads for all students Session 2 Behavior Notes 1. Hand out to students the two practicum exercises they con do subsequent to the CIOSS. Encourage them to "proctice" their skill by completing these activities. 2. Hand out all of the remoining student hondouts for Session 2 (and Session 1 if not handed out at that time.) Session 2 Section G: Content This section has been developed to bring the second half of the session to a close with a meaningful review of the material covered in the previous sections. 132 A. OVERHEAD 1 B. OVERHEADS 2-8 C. OVERHEADS 9-17 D. OVERHEADS 18-24 E. OVERHEADS 25-29 SESSION 2 A- OVERHEAD 1 C. OVERHEADS 30-34 E. OVERHEADS 35-47 133 Behavior Overhead 1 GOALS 1. Understand that people ofien respond in a disruptive, dangerous manner because we are not providing supports and services that meet their needs. 2. Recognize that helping another person change his/her behavior will probably require a comprehensive plan that deals with all major aspects of the person's life. 3. Recognize that, with challenging behavior, first individualize services to better meet the person's needs rather than using rewards and punishments on "TARGET BEHAVIORS." 4. Recognize that there are many causes for, challenging behavior. 5. Distinguish between simply managing a person's behavior versus supporting her/him in learning to change through listening, negotiation and effective positive teaching strategies. 135 Behavior Overhead 2 A COMMON STORY Behavior Problem Bob has severe tantrums. Sometimes it takes several of us to calm him down. Behavior Plan If Bob does not comply after you ask him at least two times to "CALM DOWN, " escort him to the time out room and make sure that he stays there until he is calm - at least for 15 minutes. Results Since the time out plan was implemented the frequency of tantrums has been reduced by 50% However, he still has 7 to 10 tantrums each week. 137 Behavior Overhead 3 SHOULD WE CONTINUE THE TIME OUT PROGRAM? WHAT CHANGES COULD WE MAKE? FIRST, HOWEVER, YOU NEED TO KNOW THAT: "Bob lives in the `WRONG' place" "Bob lives with the `WRONG' people" "We don't have enough staff" "We haven't had appropriate training" "He hates his day program at the workshop" 139 Behavior Overhead 4 "NOW YOU KNOW THE WHOLE STORY. WHAT DO YOU THINK . . . WOULD INCREASING THE TIME PERIOD TO 30 MINUTES BE MORE EFFECTIVE? Mr. Louis had described five major problems that were probably directly contributing to Bob's tantrum behavior. A "TIME OUT" program will not improve any of the five problems. What right do we have to try to "make Bob behave appropriately" (shut Up about what is bothering him) without first trying to meet his needs by dealing with some of the things that are disturbing him? Behavior Overhead 5 HOW MIGHT BOB BENEFIT BY THE TEAM ACKNOWLEDGING THAT THERE ARE PROBLEMS IN BOB'S LIFE THAT ARE DIRECTLY CONTRIBUTING TO HIS CHALLENGING BEHAVIOR? Once the problems are identified it may be possible to modify Bob's service plan to deal with at least some of them now. If the necessary changes can't be made immediately, it would still be possible to make plans for the changes to be made once it does become possible. 143 Behavior Overhead 6 HOW MIGHT BOB BENEFIT? It might help to reduce the resentment that people feel when they are the target of Bob's challenging behavior. Understanding that at least some of the reasons for Bob's challenging behavior are conditions that they (the system) helped create - which he probably had no choice in - may help people be more supportive. There is no doubt that everyone, including Bob, will benefit if he can learn less disruptive ways to show his discomfort and ask for help. What better way to begin the teaching process than by first showing him that are trying to help make things better for him? 145 Behavior Overhead 7 BEFORE ASKING HIM TO CHANGE. Is there any doubt that it would be easier to help Bob learn to handle frustration and disappointment if they could first reduce some of the frustration and disappointment in his life? 147 Behavior Overhead 8 Behavior Overhead 9 QUESTIONS TO ANSWER: Step 1: "what is it that seems to disturb, frustrate or upset the person?" "Are there situations or settings that seem to disturb or upset the person?" Step 2: "How do you know that the person is disturbed or upset by these situations?" "HOW did the person let you know that they were upset?" Step 3: "When the person is faced with these types of disturbing or frustrating situations what do you think he/she needs from other people?" "What help or support might the person ask for if she/he could clearly communicate?" Behavior Overhead 10 Step 1: "What is it that seems to disturb, frustrate or upset the person?" "Are there situations or settings that seem to disturb or upset the person?" ExampIe 1: Mary has severe hearing and visual impairments. Is disturbed when confused about what work she is supposed to be doing Has trouble in making transitions from one assignment to the next. 153 Behavior Overhead 11 Step 2: "How do you know that the person is disturbed or upset by these situations?" "How did the person let you know that they were upset?' Example 1: Mary shows that she is upset or confused by biting her hands, pulling at her hair and sometimes slumping to the floor. 155 Behavior Overhead 12 Step 3: "When the person is faced with these types of disturbing or frustrating situations what do you think he/she needs from other people?" "What help or support might the person ask for if she/he could clearly communicate?" Example 1: A clear way to understand what task or activity she was to be working on. A way to know when it was time to change tasks. They selected objects that were associated with each task or activity and began to use them as prompts. For example: dimer plate to cue the activity for "setting the table". Things improved more when Mary began using the "communication objects" to show the staff what she wanted to do. 157 Behavior Overhead 13 Step 1: "what is it that seems to disturb, frustrate or upset the person?" "Are there situations or settings that seem to disturb or upset the person?' Example 2: Bob does not do well in noisy situations. He is very sensitive to loud sounds he has no control over. Noisy crowds really upset him. 159 Behavior Overheod 14 Step 2: "How do you know that the person is disturbed or upset by these situations?" "How did the person let you know that they were upset? ExampIe 2: Bob lets people know he is upset by putting his hands over his ears, yelling or running away. He may hit people who are noisy. Or turn his radio up to "DROWN OUT" the noise. Behavior Overhead 15 Step 3: "When the person is faced with these types of disturbing or frustrating situations what do you think he/she needs from other people?" "What help or support might the person ask for if she/he could clearly communicate?" Example 2: Bob would ask for people to stop making so much noise and to be allowed to spend more time alone or with only a few people. Bob switched bedrooms to be further away from the noise of the home. Bob was shown how to use a portable radio with earphones. At work he was removed from the major flow of noise and activity and allowed to wear earphones. 163 Behavior Overheod 16 EXAMPLES OF AVERSIVE BEHAVIOR MANAGEMENT: Step 1. Bob does not do well in noisy situations. He seems to be very sensitive to loud sounds, especially those that he has no control over. Crowds, especially noisy ones, really upset him. Step 2. Bob doesn't talk but he does let people he is upset in a variety of different ways. He may put his hands over his ears, begin to yell and even run away. He may attempt to hit the people who are being noisy. If he is in his room he may turn his radio up to "drown out" the noise of the other people 'in the group home. Step 3. Bob's radio is taken away for 15 minutes each time he plays it too loud. If Bob remains agitated he is placed in the time out room until he calms down. 165 Behavior Overhead 17 EXAMPLES OF ABRASIVE BEHAVIOR MANAGEMENT: Step 1. Mary, who has severe hearing and visual impairments, seems to be disturbed at her day program when she becomes confused about what she is supposed to be doing as her work assignment. She also has trouble in making transitions from one assignment to the next. Step 2. Mary shows that she is upset or confused by biting her hands, pulling at her hair and sometimes slumping to the floor. Step 3 Mary's teacher sprays a water mist in her face when she pulls her hair or yells. She is given candy for remaining quiet. 167 Behavior Overhead 18 GREAT AND DESPERATE CURES In the late 1800s a German neurologist published a book on electrotherapy. Weak electric currents were used to "stimulate the patient's nervous system" and improve behavior. Electrical stimulation device invented by Dr. John Butler of New York. It was said to be "especially salubrious in cases of rheumatism, nervous exhaustion, neuralgia and paralysis. (From Harper's, 1881) 169 Behavior Overhead 19 NAVANE "Everything seems to work better including me" "It feels good to be useful again" For the chronic psychotic patient, Navane can mean improved motivation and more competent work performance. Improvement generally occurs without serious side effects. Behavior Overhead 20 SINEQUAN (doxepin HCL) Restores life's true colors. Anti-depressant effectiveness with once-a-day dosing. Behavior Overhead 21 SIBIS The result of a Mother's Plight. Self-Injurious Behavior Inhibiting System A New Concept in Aversive Therapy Extinguishes Self-Injurious Behavior When Nothing Else Works. 175 Behavior Overhead 22 Behavior Overhead 23 PEOPLE WITH CHALLENGING BEHAVIOR Given the above way of thinking, is it surprising that when we are faced with helping support a person with disabilities who has severe behavior challenges that we adopt the: "Quick Weight loss" Approach to Behavior Change 179 Behavior Overhead 24 NON-COMPLIANCE TRAINING PROGRAM 1. Begin a compliance training program to establish control over Joey's behavior. This program involves: a. 3-4 training sessions conducted daily. Present specific tasks that Joey can do. Compliance more important than meaningfulness. b. When Joey first attempts to run away or tantrum, he should be immediately brought back to the on-going task and required to comply. Physical prompts and manual guidance may be used. 2. A time out program to reduce his aggressive and non-compliant behaviors. Ignore self- injurious behavior. 3. Frequent reinforcement for his positive social behaviors and interactions. Behavior Overhead 25 LEROY Big and strong. Labeled as moderately retarded and mentally ill. Assigned to the work adjustment group at the workshop. Has the skills for real work but doesn't get to because of his dangerous and disruptive behavior. MOST OF HIS TIME IS SPENT IN "MAKE WORK" 183 Behavior Overhead 26 TYPICAL WORKSHOP SITUATION: Leroy starts on a new task that he already has the skills to complete. After a short period of work, he begins to ask for a break Following the behavior plan, his supervisor ignores the requests. Leroy becomes more upset. The supervisor continues to ignore him, and Leroy moves away from the table. He refuses requests to return to the table, so the instructor takes the work to him. 185 Behavior Overhead 27 TYPICAL WORKSHOP SITUATION: At first Leroy cooperates. The supervisor tries to move Leroy back to the table. Leroy says No! The supervisor tries again, becomes more assertive. Leroy yells No! The supervisor tries to drag the chair to the table, and Leroy slams his arms down and begins to yell. The situation escalates until Leroy "EXPLODES," is sent home and expelled from the workshop. 187 Behavior overhead 28 RALPH Good natured, well-behaved. Almost always follows instructions, you never have a problem with him. Most community programs are designed for people like Ralph. Look at: o PROGRAM HISTORY. o STAFF RATIOS. o STAFF TRAINING. o PROGRAM OPTIONS. o CLIENT CHOICES. o RULES/REGULATIONS. 189 Behavior Overhead 29 WE DESIGNED THE PROGRAM FOR RALPH, AND THEN LEROY SHOWED UP! Behavior Overheod 30 UNDERSTANDING BEHAVIOR CHALLENGES - BASIC ASSUMPTION: There are always reasons for why people do what they do. The first step in helping people change their behavior is to understand the causes for their behavior. Behavior Overhead 31 PHYSICAL CAUSES FOR PROBLEM BEHAVIOR: Do occur but only rarely. When in doubt, check it out. Careful physical exams are even more important with people who have difficulty communicating with us about how they feel. Inappropriate use of behavior controlling medication can be a cause for challenging behavior. Behavior Overhead 32 ENVIRONMENT CAUSES: Our behavior is strongly influenced by our environment, especially our learning experiences. Vicious cycle: Feel angry, confused, bored. I may... Respond by hurting myself or others, yelling, crying. Then I discover... Aggressive, disruptive behavior works for me. Things I don't like or don't understand can cause me to... Feel angry... 197 Behavior Overhead 33 199 Behavior Overhead 34 LOOK AT THE SITUATION THROUGH LEROY'S EYES: Leroy does not have a positive working relationship with anyone at the workshop. Why should he care whether they are pleased with his behavior? Why should he change his behavior based on their criticism? If Leroy behaves himself - follows instructions, does not cause trouble, etc., he will probably be ignored, At times he may be praised for his appropriate behavior, but that is nothing compared to the immediate attention provided by the "crisis team" when he is disruptive - he becomes the center of attention, for the entire workshop. 201 Behavior Overhead 35 CARL'S STORY BRIEF REVIEW: Carl works in a group home Carl has trouble getting Merle ready for work on time. Mary, Carl's supervisor, has talked to him about the problem. It hasn't helped. Mary then developed a disciplinary procedure based on threats and reprimands (punishment). 203 Behavior Overhead 36 ANALYSIS: It is clear that Mary did not make an attempt to find out why Carl was having a problem getting Merle ready on time. Her plan is based on the assumption that the only reason for Carl's "FAILURE" is that he doesn't care enough - is not motivated enough: . The threat of punishment (reprimands and firing) . The promise of reward (increase in pay) will provide the motivation. 205 Behavior Overhead 37 ANALYSIS: (CONT.) However, if it is not a problem of motivation, her plan will probably fail. Punishment for failing and rewards for succeeding won't: o Provide Carl with the teaching skills he needs to work well with Merle. o Solve the problem of too few staff. Mary should have first attempted to find out why Carl was having problems and tried to help based on this. 207 Behavior Overhead 38 KATHY'S STORY She was nine years old. Lived at the institution for 9 months. She had difficulty adjusting to her school program. Lots of tantrums and running away. These behavior problems gradually decreased. She began throwing up in class At first only infrequently, later every day. Drugs didn't help. School exclusion didn't help. Most of the time she was returned to her ward to be cleaned up. Often she did not return to school. They developed a BEHAVIOR PLAN. 209 Behavior Overhead 39 POTENTIAL REASONS FOR KATHY'S CHALLENGING BEHAVIOR. CHANGES WE MIGHT MAKE: Behavior Overhead 40 BEHAVIOR PLAN SUBJECT: Kathy D. BEHAVIOR: Vomiting behavior. Throwing up anywhere and anytime while at school. BASELINE: Every day but only once per day, Kathy is usually returned to her cottage after throwing up which artificially limits the frequency of the behavior. ANALYSIS: Kathy may be throwing up either because (1) she wants to leave the class or because (2) she wants to return to her cottage. Behavior Overhead 41 The current procedure of allowing her to leave the class and return to her cottage immediately after throwing up may be serving to reinforce the vomiting behavior. BEHAVIOR PLAN: We must stop the reinforcement for the vomiting behavior. From now on Kathy will not be allowed to leave the classroom and return to her cottage. She must remain in the classroom until the end of the school day. Cottage staff should provide extra clothes so that Ms. Hits can change her clothes in the classroom. The vomiting behavior must be ignored as much as possible. If it is necessary to change her clothes she should not be talked to and under no circumstances should anyone act upset. This is an extinction program. If Kathy goes at least ten minutes without throwing up, or trying to throw up, she should be praised (reinforced) and given two M&Ms. 215 Behavior Overhead 42 CHART OF FREQUENCY OF VOMITING Behavior Overhead 43 All of us will have to deal with a person whose behavior, at times, is disturbing, dangerous, disruptive. WHAT CAN WE LEARN FROM KATHY'S STORY? First try to understand the causes for the person's behavior. Ask why? Try to figure out how the behavior works for them. Ask what you might be able to do to help the person - not just eliminate the "BEHAVIOR PROBLEM." Do not be satisfied with a plan that simply manages the person's behavior. Often a person's disruptive behavior should be thought of as communication and should be "LISTENED" to. Behavior Overhead 44 RESULTS: Kathy threw up a lot at first - 23 times on the third day of the behavior plan. Gradually over a 30 day period the vomiting was eliminated. She never threw up in class again. IS THIS A SUCCESS STORY? From the point of view of the: Teacher? Behavior specialist? The other students? 221 Behavior Overhead 45 WHAT ABOUT KATHY? Is it a success story from her point of view? Would she say - "I love it at school!" "I wish everyone had such a nice behavior plan!" OR MIGHT SHE SAY: "I still hate it here!" "I'm still bored, frightened, confused." "I just don't tell anyone about it anymore!!" 223 Behavior Overhead 46 LOOKING AT WAY's "PROBLEM" BEHAVIOR AS COMMUNICATION: Kathy said "I want to leave" in many ways: She ran out of the classroom. She had temper tantrums The teacher was told to ignore these behaviors. However, vomiting did work. From Kathy's point of view the teacher finally understood that she wanted to leave. In a sense the teacher "REQUIRED" Kathy to vomit in order to leave the classroom. It was the only "SIGN" that worked. 225 Behavior Overhead 47 THE CAUSE(S) FOR KATHY'S VOMITING BEHAVIOR: THE CHANGES THAT MIGHT BE MADE IN THE CLASSROOM BASED ON THESE CAUSES: 227 SESSION 1 B. HANDOUT 1 C. WORKSHEET 1 D. HANDOUTS 2-3 F. HANDOUT 4 G. WORKSHEET 2-3 SESSION 2 B. WORKSHEETS 2-3 C. HANDOUT 5 E. HANDOUTS 6-7 G. WORKSHEETS 4-6 229 Worksheet 1 A Common Story step 1 : WHAT IS IT THAT SEEMS TO DISTURB, FRUSTRATE OR UPSET THE PERSON? ARE THERE SITUATIONS OR SETTINGS THAT SEEM TO DISTURB OR UPSET THE PERSON? Step 2: HOW DO YOU KNOW THAT THE PERSON IS DISTURBED OR UPSET BY THESE SITUATIONS? HOW DID THE PERSON LET YOU KNOW THAT THEY WERE UPSET? 231 Step 3: WHEN THE PERSON IS FACED WITH THESE TYPES OF DISTURBING OR FRUSTRATING SITUATIONS WHAT DO YOU THINK HE/SHE NEEDS FROM OTHER PEOPLE? WHAT HELP OR SUPPORT MIGHT THE PERSON ASK FOR IF SI-IE/HE COULD CLEARLY COMMUNICATE? (MAKE SURE THAT YOU TRY TO ANSWER FROM THE PERSON'S POINT OF VIEW-NOT FROM THE POINT OF VIEW OF WHAT YOU THINK HE/SHE NEEDS). 232 Worksheet 2 Ralph's Story In-class Exercise PURPOSE: To gain experience in looking at the world from the point of view of the person with challenging behavior. To help in understanding why challenging behavior occurs, which is the first step in helping the person change his/her behavior. DIRECTIONS: 1. Select a person you know well who has been labeled as having challenging behavior. 2. Develop an explanation for the person's challenging behavior from her/his point of view. Try to understand and be able to explain why the person often engages in the challenging behavior. Look at the situation from the person's point of view. my would the person say, if he/she could communicate clearly and accurately, they did what they did? YOU COULD LOOK AT FACTORS SUCH AS: o Have there been inconsistencies in staffing, scheduling that are difficult for the person to understand and accept? o Are there situations that we know the person has a difficult time dealing with such as crowds, loud noises etc. but are still a part of her/his everyday life? o How much choice does the person have over who they live or work with? o Does he/she have any real friends? Especially friends who advocate on behalf of the person.. o How well do we do at communicating with the person? o How well do we understand the person's attempts to communicate? o How much of the person's program really reflects his/her individual needs? IMPORTANT: From the person's point of view, from his/her own experience, does the challenging behavior work? Does it help the person gain what they want? Escape from or avoid what they do not want or like? 233 MOST IMPORTANT: Does the person really have any other options or choices that also work, or, is her/his situation similar to Leroy's? Leroy didn't know of some of the options that might have been available to him. He might have been able to complain to his case manager or his legal rights representative but he didn't know he could. However, he did know that saying he didn't want to work, even asking repeatedly to stop, did not work. From his point of view disruptive and aggressive behavior worked almost every time. We might be able to see that his aggressive behavior also caused Leroy lots of problems, but when you have no other alternatives you go with your experience and usually continue with what has worked most of the time. 3. Use the following space to record your conclusions. 4. Prepare to explain the reasons for the person's challenging behavior to your fellow students. 234 Worksheet 2 continued AS YOU THINK ABOUT WHAT YOU ARE GOING TO SAY, KEEP THE FOLLOWING POINTS IN MIND: o Please talk for the person. In other words, use first person statements. Use language like "I sometimes do the following things ......," `The reasons I often bite my hand are . . . . . . . This may seem awkward at first, we are all more used to talking like "The client's challenging behaviors are . . . . . or "The learner has behavioral difficulties because of the following ..." but it is very important that you present the person's case as exactly as you think they would, if they could. o Don't worry about coming up with solutions or answers as to how to deal with the challenging behaviors yet. In this exercise we are simply trying to improve our understanding of the causes or reasons for challenging behavior. Don't let anyone convince you that your understanding must be wrong simply because you don't have a ready solution to the problem. o This is not a debate and there are no obvious right or wrong answers. IMPORTANT NOTE: Keep in mind, we are not trying to condone or apologize for the person's disruptive or aggressive behavior. We are simply trying to understand why the person engages in the challenging behavior. To say "I understand why Leroy acts so disruptive and sometimes dangerous" is not the same as saying "I accept his behavior - it's O.K. for him to hurt others." Listening to, understanding and in a sense respecting the person's reasons for his/her behavior, is the f~st step toward helping the person make more adaptive, less dangerous choices. 235 Worksheet 3 Ralph'ss Story Practicum Trying to understand why people engage in challenging behavior by looking at the world from their point of view. PROCEDURE: 1. Choose at least two different situations in which the person you selected engaged in behavior that was disruptive or possibly dangerous. 2. Use the space provided on these two pages to document potential reasons for the challenging behavior, from the point of view of the person. YOU COULD LOOK AT FACTORS SUCH AS: Have there been inconsistencies in staffing, scheduling that are difficult for the person to understand and accept? Are there situations that we know the person has a difficult time dealing with such as crowds, loud noises, etc., but are still a part of her/his everyday life? How much choice does the person have over who they live or work with? Does he/she have any real friends? Especially friends who advocate on behalf of the persod How well do we do at communicating with the person? How well do we understand the person's attempts to communicate? How much of the person's program really reflects his/her individual needs? SITUATION 1: Briefly describe what happened (who did what to whom?') If the person could communicate clearly what might she/he say were the reason(s) for the problem behavior? 237 Describe facts about the person's life, things you know about the services that are provided to support what they have to say. SITUATION 2: Briefly describe what happened (who did what to whorn?) If the person could communicate clearly what might she/he say were the reason(s) for the problem behavior? Describe facts about the persons life, things you know about the services they are provided that support what they have to say. Be ready to describe what you have learned to the other students and defend your conclusions. 238 Worksheet 4 Management vs. Listening 9 Practicum Exercise EXAMPLE 1: Select a person with challenging behavior that you know well. Think back about the person's past, look through appropriate records and identify at least one example of when the person'ss challenging behavior was managed rather than "LISTENED TO" - when a pkm involving rewards and/or discipline was used to decrease the person's challenging behavior which was not based on the causes for the person's behavior. Document: A description of the challenging behavior A description of the behavior plan The results of implementing the plan Any ideas you have about the potential causes for the challenging behavior and what might have been done to help rather than implementing the behavior plan 239 EXAMPLE 2: Using the same person as above, or picking a new person whom you also know well, identify at least one example of when the person's challenging behavior was "listened to" rather than managed - when a plan based on the causes for the person's behavior was implemented. Document: A description of the challenging behavior A description of the changes staff made in setting, activities, demands, schedule, etc. to better meet the needs of the person The results of implementing the plan Ideas you have about why the plan worked, if it did or did not succeed. 240 Worksheet 5 Management vs. Listening Practicum Exercise 1 DESCRIPTION OF THE CHALLENGING BEHAVIOR DESCRIPTION OF THE BEHAYIOR PLAN 241 RESULTS OF IMPLEMENTING THE PLAN IDEAS YOU HAW ABOUT THE CAUSE(S) FOR THE CHALLENGING BEHAVIOR AND WHAT MIGHT HAW BEEN DONE DIFFERENTLY TO HELP THE PERSON 242 Worksheet 6 Management vs. Listening Practicum Exercise 2 DESCRIPTION OF THE CHALLENGING BEHAVIOR DESCRIPTION OF THE PLAN TO HELP/SUPPORT THE PERSON RESULTS OF IMPLEMENTING THE PLAN IDEAS YOU HAVE ABOUT WHY THE PLAN WORKED, IF IT DID NOT SUCCEED. 244 Handout 1 A Common Story At a regional training conference several years ago, the organizers arranged for an evening session during which the participants could talk informally with the presenters about working with people with challenging behaviors. The participants wanted to describe the problems they faced and hoped that the presenters would have something to share that might help them do a better job. The presenters were not sure they helped anyone that night. But they learned a very important lesson. They learned the lesson because five different people told them the `same" story. The specifics of each story were of course different - but the fundamental message was the same. Here is what happened. Each participant began his or her story by describing a person with challenging behavior. Each person was different, as were their behaviors. One fellow was described as having severe temper tantrums, a woman hit herself in the head repeatedly, a student bit and kicked other students, etc. Each was the subject of a behavior plan designed to decrease or eliminate the challenging behavior. FOR EXAMPLE: o The man with the severe temper tantrums was being forced to sit alone in an empty room for 15 minutes if he cried (a time out program). o The woman who was self-injurious was ignored when she hit herself (an extinction program). She was frequently praised when she did not hit herself. o The student earned tokens when he did not act aggressively towards other students and was denied access to his favorite activity when he did (a DRO/punishment program), Each of the participants explained that they were not totally happy with the results of the plans. The behavior of some of the people had improved after the plans were implemented, but not enough to be satisfied with the results. For example, one of the participants (Mr. Louis) worked in a group home and he described a man (Bob), with severe temper tantrums, He said that while the time out program had reduced the frequency of temper tantrums by 50%, Bob was still having seven to ten tantmms each week. The tantrums were described as a serious problem. Mr. Louis said that if it weren't for the tantrums Bob could move to an apartment living program - which he really wanted to do. 245 Mr. Louis wanted to know if the program was appropriate for Bob - had any chance of working more effectively, etc. But first, he said "Wait, before you answer, there are a few more things you need to know about Bob." YOU NEED TO KNOW THAT: "Bob Iives in the `wrong' place." He used to live in an apartment of his own but he lost his job and couldn't afford to stay there. Our group home was the only available placement. "Bob lives with the 'wrong' people." The other men in the group home all have mental retardation and are far less skilled than he is. He refuses even to admit that he is mentally retarded and wants nothing to do with his housernates. "We don't have enough staff." In addition to the tantrums, Bob steals from his housemates. We don't have enough staff to provide for appropriate supervision. "We haven't had appropriate training." Bob has very limited speech, but hardly any of the staff know how to sign. The psychologist says that Bob has serious mental health problems - we don't know what that means. "He hates his day program at the workshop." When Bob lived in the apartment he had a good job working for a landscaping company. He lost that job when he was moved to the `group home, He couldn't get to work on time from our side of town. He hates "sit down-packaging" type work. "Now," said Mr. Louis, "you know the whole story. Anyway, we've been thinking of doubling the duration of the time out period from 15 to 30 minutes. What do you think? Might that work?" 246 Handout l continued I am not trying to make fun of Mr. Louis. His question about increasing the time out period might have been misguided but it was sincere. However, he had just clearly described five major problems in Bob's life - each of which was probably contributing direcdy to temper tantrums. He did not seem to see that the time out program, no matter what the duration, had nothing to do with, and could not help correct, these problems. The presenters didn't know what to say. It wasn't simply that increasing the time out period to 30 minutes was doomed to fail. Maybe if Bob was really afraid of, or hated the isolation, he would have fewer tantrums. There is no doubt that if we are "bigger," more "powerful" than Bob we can probably devise a sufficiently aversive procedure so that he will learn to stop telling us about what bothers him. No matter how troubling it is to him to live where he is not happy, to live with people he dislikes, to work at a job he finds boring and low paying, we can probably devise a reward or punishment procedure to shut him up. But will we or Bob have gained much? Is there any reason to be happy if the time out program does succeed in eliminating the temper tantrums? Should we celebrate the fact that we have found a way to force a person to live where he doesn't want to, with people he dislikes and to work each day at a job he hates but at the same time keep quiet about it? Of course, the details of each of the other participants' stories were different. But a fundamental theme ran through each of the five stories. 247 STORY THEMES 248 Handout 1 continued 1. Person with a disability engages in behavior that is disruptive, harmful, dangerous (challenging behavior). 2. Members of the service planning team are usually aware of factors in the person's life that are contributing to the challenging behavior. 3. A Behavior Plan is implemented to decrease the targeted behaviors. The Plan usually involves some combimtion of the following: o Elimimting any reinforcement for the "PROBLEM" behavior (extinction). o Making sure that the consequences of the target behavior are unpleasant, through the use of privilege removal, restrictions, painful stimuli, etc. o Providing powerful rewards for not engaging in the "PROBLEM" behavior. 4. If plan does not produce the desired changes, the "POWER" of the rewards and punishers is increased. More aversive consequences are used. Items and activities even more important to the person are withheld, to be given later as rewards for appropriate behavior. 5. Throughout the process, factors that are clearly influencing the person's behavior such as where they live, with whom, activity schedules, choices, etc., remain largely unchanged. 6. Far too often the results are: o There is not sufficient improvement in the challenging behavior and the person is suspended from the service program. o The behavior plan is "SUCCESSFUL", but only after very restrictive procedures are implemented. 249 All of the participants showed, in the telling of their stories, that they were aware, at least at one Ievel, that a number of factors were contributing to the person's challenging behavior. However when it came to actually doing something to help, they acted as if they did not understand. Surely none of the members of Bob's service planning team believed that he was having severe temper tantrums because he had been "DEPRIVED" of time out. In the past, didn't they understand that the use of time out, for whatever duration, would do nothing to alleviate the problems caused by his placement in the group home and work assignment YOU MAY BE THINKING: "So what? What is to be gained by acknowledging these other factors? How will this help Bob?" Well, of course there is at least one obvious benefit. If the team clearly acknowledged that Bob's residential and work placement were not meeting his needs, that they needed more trained staff, etc.- they or someone else just might do something about it! People who know a person well and are personally committed to supporting the person can often develop a plan, centered on the specific needs of the person, and help make the kinds of major changes not one of them believed was possible. But you're right if you are thinking that it is often not possible to make immediate changes, even though they may be desperately needed. A very real absence of available alternatives probably did "FORCE" the team to accept Bob's initial placement at the group home and workshop. At the time there probably was not enough money to pay for extra staff or more training. However, unless the team explains, in Bob's plan, that they feel that his challenging behavior is at least partially caused by their weaknesses (inappropriate placement, lack of training, etc.) the needed changes may never be made, even if they become possible. For instance, if funds do become available, why would the administrators of the agency which serves Bob hire extra staff or arrange for advanced staff training - if they believe that Bob simply needs a more powerful behavior plan? If they see the issue as only "BOB'S PROBLEM" not "OUR PROBLEM. " 250 Handout 1 continued Even if it seems necessary to accept the current situation for the foreseeable future it is still important to acknowledge that we are part of the problem, not just Bob. Have you ever noticed how despite your best intentions you find yourself feeling resentful towards a person with challenging behavior? Especially if you have been a target of their "CHALLENGE?" Ever been mad at the person when a plan that "OUGHT TO WORK" is failing? Clearly some of this is just human nature. It shows you care. But, if we were honest, we would admit that far too often we hold the person responsible for actions that are clearly controlled by conditions we have helped create. Bob did not pick the group home or his housemates. He did not have a chance to vote on the tax levy that failed, causing a cut in the new staff positions. Clearly acknowledging our (the system's) role in contributing to Bob's challenging behavior should help decrease our resentment and increase our motivation to make the changes necessary to be more supportive of Bob and design the kind of individualized services that are necessary to meet his needs. 251 Handout 2 Great and Desperate Cures The history of human services is filled with many different ways we have tried to "CURE"' people with disabilities - especially people with disruptive, dangerous, challenging behavior. Valenstein has written a book titled "GREAT AND DESPERATE CURES" that provides examples such as: In the late 1800s a German neurologist published a book on electrotherapy. Weak electric currents were used to "stimulate the patient's nervous system" and improve behavior. o Electrical stimulation service inventd by Dr. John Butler of New York. It was said to be "especially salubrious in cases of rheumatism, nervous exhaustion, neuralgia and paralysis. (From Harper's, 1881) 253 o Hydrotherapy, which involved baths, douches, wet packs, steam and hoses was also used frequently in the early 1900s. o In the late 1800s, a psychiatrist inoculated patients in mental hospitals with vaccines of tuberculosis, typhoid fever, malaria and other infectious diseases. His theory was that high fever, brought on by the infections, cured his patients. He became very famous and was also very wrong. Later hot baths, hot air, radiothermy, infrared-light bulb cabinets and special electric "mummy bags" were also used to induce high body temperatures. These "treatments" were less deadly but did IittIe other than make the people very hot. o Sleep therapy or "prolonged narcosis" was used in the 1920s and 30s. Drugs were used to keep patients in mental hospitals unconscious, usually for one or two weeks - sometimes as long as a month. "Cure" rates of 70% to 80% were reported. o Other therapies have included: Using small doses of cyanide to stimulate the nervous system inducing aseptic meningitis Hypothermia, cooling the body Electroconvulsive therapy Lobotomies 254 Handout 2 continued BEFORE YOU THINK TOO HARSHLY OF OUR ANCESTORS LOOK AROUND, NOW. WHAT ARE OUR "GREAT AND DESPERATE CURES"? HERE ARE JUST A FEW EXAMPLES: NAVANE "Everything seems to work better . . . including me" "It feels good to be useful again" For the chronic psychotic patient, Navane can mean improved motivation andmore competent work performance. Improvement generally occurs without serious side effects. SINEQUAN (doxepin HCL) Antidepressant effectiveness with once-a-day dosing. Restores life's true colors. SIBIS The result of a Mother's Plight. Self Injurious Behavior Inhibiting System A New Concept in Aversive Therapy Extinguishes Self-Injurious Behavior 255 The need to find THE "KEY TO THE PROBLEM," the "ONE THING THAT WILL SUCCEED" is clearly with us still today. This notion of a quick, dramatic solution, is not limited to the field of human services. Look at the advertisement on back. 256 Handout 2 continued ANYONE WITH EVEN A BASIC UNDERST~ING OF NUTRITION KNOWS THAT THE WAY TO STAY HEALTHY, KEEP CONTROL OF YOUR WEIGHT IS TO FOLLOW THESE GUIDELINES: o Eat well balanced meals. o Don't eat too much. o Exercise regularly. o Get enough sleep. o Don't smoke. o Drink, if at all, onIy in moderation. We all know that these guidelines are true, yet many of us often act as if they weren't. We eat too much. We smoke. We drink too much alcohol. Our major recreation is watching other people exercise on T.V. We know the guidelines are true but we also have experience that says they are difficult to follow. It is one thing to know that you should not eat too much and it's another thing to say NO to the banana cream pie. We want the advertisement on the overhead to be true. If it were true we could ignore the nutrition/exercise guidelines and just buy the "MAGIC BULLET" diet pills. This kind of thinking maintains our multi-billion dollar diet industry. It is true that a sensible diet can help some people, some of the time. It might help a person lose weight - but we all know that to maintain our health takes a lot of work and requires us to look at and possibly change many different aspects of our life. Still, we hold out hope for the special, miracle diet. Some of you are probably wondering right now, about how you might order the "FAT - AWAY MAGIC BULLETS," even at $10 a pill. 257 PEOPLE WITH CHALLENGING BEHAVIOR Given the above way of thinking, is it too surprising that when we are faced with helping suppofi a person with disabilities who has severe behavior challenges that we adopt the: QUICK WEIGHT LOSS APPROACH TO BEHAVIOR CHANGE There is a very strong parallel between the concept of a diet and that of a behavior plan. The ideal diet is one that requires very little of the user - few, if any, major changes in eating habits, no exercise - but still produces quick, dramatic results. Similarly the "IDEAL" behavior plan is one that requires very little change in our (the system's) behavior. It is easy to implement, yet results in quick, dramatic reductions in or elimination of behavior problems. Just like our interest (obsession?) in finding a miracle diet can cause us to ignore real problems such as over eating, lack of exercise, etc. the use of a "BEHAVIOR PLAN APPROACH" to supporting people with severe behavior challenges helps us ignore real issues in the person's life that need our attention. Look at the story below. 258 Handout 3 Joey's Story Joey was ten years old. He went to school in a class designated for students with mental retardation and "SEVERE BEHAYIOR DISTURBANCES." Joey, like the other boys and girls in the class, was often involved in hitting, kicking and crying. In addition, Joey usually did not follow the instructions of the teacher. Because of this behavior he had been labeled by the school psychologist as "EXTREMELY NON-COMPLIANT." Joey was sent to a university diagnostic center for further evaluation. The evaluators agreed that he was indeed "NON-COMPLIANT" and recommended the behavior plan that follows. NON-COMPLIANCE TRAINING PROGRAM 1. Joey's parents and school staff begin a compliance training program as a first step in establishing control over his behavior. This program involves: A. W training sessions lasting about 10 minutes should be conducted daily. During these sessions spe~lc tasks that you know Joey can do should be presented. The meaningfulness of the tasks is secondary to requiring compliance to demands of the task situation. B. When Joey first attempts to run away or tantrum he should be immediately brought back to the on-going task and required to comply. Physical prompts and manual guidance may be used to guide him through the task. A new activity should not be introduced until he has complied with the original task. Reinforcement should not be given until the entire task is completed. 2. A time out program should be implemented in order to reduce his aggressive and non-compliant behaviors. His self-injurious behavior should be ignored. If he becomes aggressive or repeatedly refusw to comply to demands, he should be escorted to the time out room and be required to remain in the room for a minimum of 10 minutes. 3. He should receive frequent reinforcement for his positive social behaviors and interactions. 259 Their plan was based on the assumption that the only problem to be solved was Joey's BEHAVIOR (not following instructions and refhsing to behave himself) and that the solution could be as simple as the implementation of a behavior plan. The evaluators believed that the school staff could "FIX" Joey (teach him to be compliant) in only 30-40 minutes of training each day. There was no need to need to change anything else - just implement the behavior plan (diet) and his problem would be solved. Similar to the way special diets ignore the principles of good nutrition this type of limited behavior plan ignores the fundamentals of good teaching. The members of Joey's evaluation team apparently did not attempt to answer any of the following questions: Does Joey trust his teacher, feel safe in the classroom Does Joey enjoy any of his classroom activities? Does Joey get to choose any of his assigned activities? Are the assigned tasks too challenging? ..too boring? Does Joey know how to say "No" in any other way than by being aggressive or disruptive? Would Joey's teacher honor his saying "No" if he weren't aggressive? There are of course many more questions we would ask if we were making a serious attempt to understand why Joey behaves the way he does and to then develop a teaching plan that calls for changing all the relevant factors. We would base our plan on an understanding that: 1. We (the system) are the ones who will have to change the MOST. 2. We will have to change FIRST, if Joey is to be helped. We would understand that much about the classroom environment may need to change, not just Joey's behavior. 260 Handout 3 continued After deciding not to implement the behavior plan the school staff spent time in Joey's class, trying to get an over-all picture and not just focusing on his "NON-COMPLIANT" behavior. His parents and staff asked questions such as: What does Joey like to do? What does Joey do well? What real choices does Joey have? What mistakes have we made in the past? Are we repeating them now? WHAT THEY FOUND WM INTERESTING, FOR EXAMPLE: o Joey's teacher admitted that in her opinion, "Joey did not like any of the tasks he was assigned in the classroom." o He did enjoy recess and music class, but had been excluded from both because of his disruptive behavior. o Joey's teacher said she allowed him to choose most of his educatioml assignments. However, she admitted that the only real choices presented to Joey were to: (1) Do something he did not want to do, when asked by the teacher. (2) Refuse the teacher's request. o The teacher aide almost never ASKED Joey to do things. He usually TOLD him what to do, in a very demanding tone of voice. o Mike, the student who sat next to Joey, had frequent temper tantrums and also often refused to follow the teacher's instructions. Mike's tantrums seemed to keep Joey on edge and it seemed like he might be imitating some of Mike's more aggressive behavior. 261 BASED ON THESE OBSERVATIONS THE SCHOOL STAFF MADE A NUMBER OF CHANGES IN THEIR TEACHING AND SUPPORT PROCEDURES. FOR EXAMPLE: o It was not possible, at that time, to move Joey to a class where he could spend more time with students who would serve as better role models. However, they were able to arrange for Joey to spend more time in other classroom settings - especially gym class and music. It took extra staff to make these arrangements work, but they showed the school administrators that they had already been using extra staff to intervene in crises created by Joey's aggressive behavior. o The teacher arranged for a few new classroom activities, based, on choices made by Joey. The activities weren't clearly "EDUCATIONAL" but staff figured that once Joey was happier about being in class they could gradually introduce more educationally oriented activities. o The aide tried to be more supportive and made less demands on Joey. He learned to ask rather than command. NOW of course these and the other changes implemented by the staff did not result in immediate, dramatic changes in Joey's behavior - but then neither would the compliance training behavior plan. The staff came to see that there would be no quick solutions, no "GREAT AND DESPERATE CURE" for Joey. They also understood that Joey needed to change too. They knew that if Joey could learn to follow instructions more consistently, to complete tasks that were not always the most interesting thing to him, that they and Joey would be better off. They knew they needed to help him learn to deal with delays in getting what he wanted, to handle frustration without being so disruptive. With this in mind they also implemented a new teaching program that focused on helping Joey learn alternatives to disruptive and dangerous behavior when he was frustrated or angry. The teacher showed Joey how to raise his hand and ask for help instead of yelling. 262 Handout 3 continued Given Joey's difficulties in learning new skills his teacher knew that just demonstrating appropriate behavior and waiting for Joey to behave himself would not be enough so; 1. He had other students model the appropriate behavior. 2. He shaped Joey's behavior by at first enthusiastically rewarding any behaviors he showed in frustrating situations that were less disruptive or aggressive, 3. He rewarded Joey for following directions and completing tasks by allowing him to shift to preferred activities rather than by giving him even more work to do. The staff realized that this would take some time to accomplish and would require everyone that worked with Joey to be supportive. Looking back at the initial compliance training plan they wondered how any of them could have believed that 10 minute training sessions to "FORCE" compliance could have ever been successful. Even worse, what if they had implemented the Plan and Joey had eventually been forced to comply? Now understanding how far they had been from meeting Joey's needs, would that really have been a success? 263 Handout 4 Ralph's Story EVEN THOUGH THIS IS RALPH'S STORY, FIRST YOU NEED TO LEARN ABOUT A FELLOW NAMED LEROY. LEROY Leroy is 38 years old, about 6'2" and weighs about 195 lbs. He enjoys wearing sleeveless T-shirts, denim overalls and big, black army boots. Leroy has been labeled as moderately retarded and also having schizophrenia. People who know Leroy well are not sure about these labels, but it is clear that he finds it very difficult to learn new tasks, has great difficulty expressing himself and does, at least at times, seem to be confused by voices that he hears "in his head." The people in Leroy's life all agree that they have a very difficult time getting along with him. While at times Leroy shows a good sense of humor and can be cooperative, most of the time he fails to complete his work assignments, refuses to follow simple directions, often picks on and steals from other clients and has already injured two staff at the workshop and one at his group home. There are times when staff feel that they must hold him to protect him or someone else - it takes three or four of the strongest staff to hold him safely. Looking closer at the workshop Leroy attends might give you a better understanding of his situation. LEROY ATTENDS THE AJAX INDUSTRIAL CENTER BECAUSE: 1. Its catchment area includes the ICF/MR residential program he recently moved to. 2. His vocational rehabilitation worker decided that he was not appropriate for their services, because of his disruptive behavior. 3. It was the only program that would accept him. 265 Even though everyone agreed that his skills and past work history clearly indicated that, in most ways he fit their criteria for the competitive or supported work program, the team decided that he should be placed in the work adjustment program, At this workshop, clients are placed in the work adjustment program if they are considered not to be "READY" for more advanced programs either due to skill deficits, or as in the case of Leroy, because of "SEVERE BEHAVIOR PROBLEMS." There are seven other clients in Leroy's group which is supervised by two staff. Leroy spends most of the day assigned to "WORK" tasks that are similar to the contracts that he may some day "GRADUATE" to. However, both Leroy and his supervisors know that he does not do real work. In fact, the items that Leroy packages are unpacked by a woman working at another table in the work adjustment area. He then has the task of putting them back in the boxes again. What happened yesterday is a good example of the problems that occur at the workshop. When Leroy first sat down at his table in the work adjustment room the supervisor told him he would be working on a new job. The workshop had obtained a new contract, and he wanted Leroy to learn to complete one of the assembly tasks required in the contract work. The supervisor placed a pile of bolts, nuts, washers and bags in front of Leroy. From the beginning, it was clear that Leroy did not need to "LEARN" the task. He quickly assembled three bolts and placed them appropriately in the parts bag. The real question was not whether Leroy could learn to do the task - he already knew how - but rather whether he would do what he was told, when he was told, without being disruptive or hurting himself or anyone else. Leroy worked steadily for about 15 minutes, then he began to ask for a break. The behavior plan developed for Leroy classifies his requests for breaks as inappropriate avoidance behavior and calls for the staff to ignore him and if necessary, redirect him back to the task. The staff member followed the plan and simply ignored Leroy's repeated requests to "take a break," "get a cup of coffee," "go to the bathroom." Leroy's requests had no visible effect on the supemisor, although he did praise him the few times he did return to work. 266 Handout 4 continued After about 15 minutes of having his break requests ignored, Leroy said, "I'm quitting . . . you can't make me work," and shoved his chair back from the table. He sat there glaring at his supervisor. The supervisor ignored Leroy for about 10 minutes and then quietly asked him several times to "Please go back to work, " The first time Leroy said "No!" later he simply ignored the supervisor. The supervisor was experienced enough to know that it would be a mistake to try to force Leroy's chair back to the table. He knew that it could result in a real fight so he decided to take the work to Leroy. He picked up one of the bolt assemblies, held it in front of Leroy and asked him to please go back to work. At fust Leroy ignored him, but after a few minutes he grudgingly completed the bolt assembly. Thinking that it might now work, the supervisor said, "Let's move you back to the table." Leroy immediately said "No!" The supervisor decided to be a little more assertive and said "Come on Leroy, you know you have to work," as he put his hands on Leroy's chair. Leroy looked up at the supervisor and yelled `tNo! No! I won't." The supe~isof quickly &ci&d that it would be a mistake to back down now and began to gradually drag the chair toward the table. Leroy immediately slammed both his arms to the chair, just missing the supervisor's hands. The supervisor jumped back and said, "OK, we can't make you work - but if you don't work, you won't get paid and you don't get a break." Immediately Leroy began to yell. He threw the bolt, breaking the window in front of his table. Then he began to cry and bite his hand and lips. The supervisor told Leroy to stop. He didn't. The other work adjustment supervisor called for help. It took four of the staff about 40 minutes to calm Leroy down, once they were able to hold him in a safe position on the floor. The staff of the ICF/MR facility were called and after Leroy had calmed down they took him back to the residential facility. Later that day at a special team meeting, Leroy was suspended from the workshop for the rest of the week. The behavior specialist was instructed to develop a more powerful behavior program and be ready to implement it by the time Leroy returned next Monday. Now we can move on to Ralph. Don't forget what we've learned about Leroy. We will come back to him later. 267 RALPH Something is missing at the agency where you work! No matter where you work, whether at a group home, workshop, supported work program, etc. What's missing is an 8x1O color picture of Ralph! Ralph is 24 years old, about 5'4" and weighs in at about 155 lbs. He takes great pride in his appearance - button down collars, pressed pants - much better dressed than most of us. Ralph has Down Syndrome which makes it harder for him to learn, limits his ability to generalize what he has learned to new situations and has resulted in him being much shorter than he would like - he plays a lot of basketball. Ralph is very good natured - he smiles a lot and is very easy going. You might even say that he is "OVER" compliant. As a matter of fact you could walk up to Ralph at the workshop and ask him to run around the room four times in a row. He probably would do it - without a question - even if he had never met you before. You never have a problem with Ralph. He may not be the fastest worker at the shop, but he is reliable and very seldom complains. You may be wondering why you need a picture of Ralph for the lobby of your workshop or above the fireplace at home. Sure Ralph is a nice guy, maybe especially nice, but so are many people. Why his picture? The answer is simple - you should hang a picture of Ralph somewhere in the program, especially in a place you have to walk past every day to remind you, and everyone else that works with you that: "The Program Was Designed for Ralph!" Of course, the people who actually designed the facility and program you work in did not know the fellow named Ralph in this story, but they must have had people like him in mind when they made many of their important planning decisions. How does a person know they designed the program for Ralph, or at least for fellows like Ralph? Of course I've never even seen your program but I bet the following description is more true than not. 268 Handout 4 continued Most Cormnunity-Based Service Programs: PROGRAM HISTORY: Years ago, when the progmm began most of tie individuals had only mild or moderate disabilities. Over the years the program has begun to accept persons with more severe disabilities but still has only limited experience with persons who have severely disruptive, possible dangerous behavior. STAFF RATIOS: Most of the staff supervisors in day programs are responsible for 12 - 15 maybe even 20 employees. The ratios are better in most residential programs, one to three at best, to one to eight in some larger programs. However, it is usually more difficult to provide close supervision in home settings. 269 STAFF TRAINING: While there may be a basic insemice orientation program, few of the staff have had intensive training and guided supervision in teaching persons who have great difficulty in learning and communication, especially those with severely disruptive behavior. PROGRAM OPTIONS: Many of the individuals were placed in their paticular day or residential program because it was the best one available, sometimes the only one available. Teams try hard to make the program fit the individual but far too often it is the other way around. INDIVIDUAL CHOICES: Most teams encourage client decision making. Some individuals even have "INCREASED DECISION MAKING" as an objective in their service plan. In reality however, most of the big decisions such as program placement, work assignments, selection of housemates, daily and weekly activity schedules, what food is purchased at the store, etc. are made by people other than the individual. RULES/REGULATIONS: The agency has a policy in its by-laws that states, "Persons who are a danger to themselves or others must be expelled from the program." You are probably starting to get the picture. The program planners must have had Ralph in mind when they developed the budget, determined staffing patterns, etc. Luckily, most of the time it works for fellows like Ralph. But guess what? "We Designed the Program for Ralph" and then Leroy showed up! Leroy must feel like the tourist from Georgia who expected to get to Mexico City on a big, modern, air conditioned bus. When the bus arrived he found that it was small, old, not air conditioned (except for the hole in the roof) and was routed to Mexico City via Saint Paul, Mimesota. The tourist was even further surprised when he complained to the staff of the bus line and was told to: 270 Handout l "BE QUIET," "STOP COMPLAINING," "LOOK AROUND, NO ONE ELSE IS MAKING A FUSS." Of course, that's not how most bus lines operate - they would go out of business. When a business makes a promise to meet our individual needs and then doesn't, we expect our money back, or at the least, an apology. However, far too often human service programs operate like the bus line in this story. We operate under federal and state laws that are supposed to guarantee people with disabilities that they will receive an individualized program based on what they actually need rather than simply what is available, in the least restrictive setting, etc., etc. Most of the time programs make very sincere attempts to make good on these promises. Too often however, funding shortages, rules imposed by others that we camot change, the complexity of the needs of those we serve all make it impossible to do what we know we need to. It is nothing to be ashamed of, unless we know of improvements that could be made but are being ignored. It is also true that, even with such major limitations our programs often are helpful - especially for people like Ralph. Leroy has not learned to play the role so often demanded of people with intellectual disabilities. People with mental retardation often learn that their life is less disruptive if they say "YES"; do what they are told, rather than voice their own opinion; learn to please others rather than themselves. There is a good side to this of course. We all know that it is necessary to learn to compromise, to do things or follow instructions that don't always please us, etc. It is also clear that Leroy's life, and ours, will be more calm and less dangerous if he can learn to be a little more like Ralph. The important question is how can we support him in learning more adaptive and less dangerous ways of voicing his criticisms. 271 Handout 5 Understanding Behavior Challenges INTRODUCTION This lesson begins with the following fundamental assumption: THERE ARE ALWAYS REASONS FOR WHY PEOPLE BEHAVE THE WAY THEY DO. It is true that we camot always identify the reasons or causes for a person's - behavior. As you will see in this lesson the causes for behavior can be very compIex and diffkult to understand. However, we must begin with the working assumption that there are reasons and that if we ask the right questions we will be able to discover them and use our understanding to help the person. CAUSES FOR PROBLEM BEHAVIOR There are many different reasons why a person might be engaging in challenging behavior. For example there may be physical causes for the person's problem behavior. These conditions can be genetic as in the case of Tay Sach's Disease* or acquired later in life such as in the case of brain injuries. However, while there are examples of physical conditions which are directly related to severe behavior challenges such examples are not common and are not likely to be the cause of many of the behavior challenges you encounter. PHYSICAL CAUSES Even though physical conditions rarely account for why the person is engaging in challenging behavior they should always be checked out. There are many examples of persons engaging in self-injury such as head banging because of ear infections, chronic headaches, impacted ear canals, dental problems, temporal lobe seizures etc. Especially if a person shows a dramatic and rapid change in behavior, it usually makes sense to carefully examine whether there could be a physical cause for the behavior. ENVIRONMENTAL CAUSES Most of what we know about human behavior clearly supports the notion that our behavior is strongly influenced by our environment, especially our *Tay Sach's Disease - a genetic condition that usually results in severe self-injurious behavior. 273 learning experiences. A careful examination of the vicious cycle chart may help in your understanding of how our environment and past learriing experiences effect behavior. FACTORS THAT PRECEDE THE BEHAVIOR Common sense tells us that there are many things that make us happy, bored, confused, interested, angry, depressed, satisfied, etc. We are clearly not all the same - what bores me may interest you, what makes you mad I may think is fumy. For people with disabilities the situation is often even more complicated. For example, many people with autism are extremely sensitive to differences in touch, taste and noise. Read the following quotes from Temple Grandin, a person with autism. "Like birthday parties. They were torture for me. The confusion created by the noise makers suddenly going off startled me. I would invariably react by hitting another child or by picking up an ashtray or anything else that was handy and flinging it across the room. "Even today, sudden loud noises such as a car backfiring, will make me jump and a panicky feeling ovenvhelms me. Loud, high-pitched noises such as a motorcycle's sound, are still painful to me, " Often it may not be just one thing, it maybe a combination of many different environmental factors. See another quote from Ms. Grandin: "But as a child, the `people world' was often too stimulating to my senses. Ordinary days with a change in schedule or unexpected events threw me into a frenzy, but Thanksgiving or Christmas was even worse. At those times our house bulged with relatives. The clamor of many voices, then different smells - perfume, cigars, damp wool caps or gloves - people moving about at different speeds, going in different directions, the constant noise and confusion, the constant touching, were overwhelming." WE REACT, IN PART, BASED ON HOW WE FEEL It's not surprising that when people feel frightened, angry or in pain, they often behave in ways that are disruptive and even sometimes dangerous. Our experience tells us that when people are bored or conksed their behavior often becomes more erratic and less predictable, So far this would not present much of a problem. The real trouble begins in the next phase of the process. 274 Handout 5 continued WE DISCOVER THAT DISRUPTIVE EVEN AGGRESSIVE BEHAVIOR OFTEN "WORKS" This is when the role of learning begins to play a powerfbl role in shaping our behavior. We all learn from our experiences and tend to repeat those actions that work for us. Behaviors that work are strengthened (rewarded/reinforced) and those that don't or result in pain or discomfort are weakened and eventually eliminated. The consequences or results of our behavior are very important in determining our future actions. EVEN THOUGH THE DISRUPTIVE BEHAYIOR OFTEN "WORKS," ON A SHORT-TERM BASIS IN THE LONG RUN MORE PROBLEMS ARE CREATED Alienation, exclusion from programs, This usually increases the discomfort and confusion in the person's life, which results in even more disruptive behavior. This "VICIOUS" cycle is clearly evident in the lives of many people with challenging behavior. We can see an example of this TYPE OF CYCLE in the story of Leroy, from one of the earlier lessons. Remember the day that Leroy was assigned a new task? Let's look at that situation from the point of view of how Leroy's behavior worked, or did not work for him. Leroy worked steadily for about 1S minutes, then he began to ask for a break. The behavior plan developed for Leroy classified his requests for breaks as inappropriate avoidance behavior and called for the staff to ignore him and if necessaw, re~rect him back to the task. His supervisor followed the plan and consistently ignored Leroy's repeated requests to "take a break," "get a cup of coffee," "go to the bathroom." Leroy's requests had no visible effect on the supervisor. However, he did praise Leroy the few times he returned to work. Is it unreasomble that Leroy would rather take a break than assemble nuts and 275 bolts that someone else is simply going to take apart" The few dollars a week that he earned at this task were not sufficient to make it any more interesting. It's worth noting that it is also not all that unreasonable, at least from a staff point-of-view, that Leroy's supemisor wanted him to complete the packaging tasks. There was an objective related to work on Leroy's 1P and if he did well he thought Leroy might be able to "graduate" from the work adjustment program and join the other employees on the workshop floor. The supervisor would probably say that he is trying to teach Leroy to "work consistently" by praising him and that by ignoring Leroy's complaining and asking for frequent breaks he will learn that such behavior is inappropriate. Leroy might tell a different story! He might say that he is learning that "it does not help to ask to stop work. " He might say that "no one listens to me" and that he has no role in decision making at the workshop. After about 15 minutes of having his requests for a break ignored, Leroy said "I'm quitting . . . you can't make me work" and shoved his chair back from the table. He sat there glaring at his supervisor. The supervisor ignored Leroy for about 10 minutes and then quietly asked him several times to "Please go back to work. " The first time Leroy said "No!," after that he simply ignored the supervisor. From Leroy's point of view he had finally found something that worked. If the supervisor wouldn't let him have a break he would just go ahead and take matters into his own hands. Is it surprising that he refuses the supervisor requests to return to work? What has he got to gain, other than a little praise and probably more work? The supervisor was experienced enough to know that it would be a mistake to try to force Leroy's chair back to the table. He knew that it could result in a big fight so he decided to take the work to Leroy. He picked up one of the bolt assemblies, held it in front of Leroy and asked him to please go back to work. At first Leroy ignored him, but after a few minutes he grudgingly completed the bolt assembly. Thinking that it might now work, the supervisor said, "Let's move you back to the table. " Leroy immediately said "No!" 276 Handout 5 continued It was probably a very wise decision for the supervisor to decide not to force the issue with Leroy by attempting to immediately drag his chair back to the table. He waited till Leroy calmed down a little and then "took the work to him." He wanted to teach Leroy, as gently as possible, that he could not avoid work by moving away from the table. It's not clear why, but Leroy cooperated, at least at first. Did Leroy's coopemting work, from his point of view? Not really. The supervisor said "Good working Leroy" but then proceeded to try to get him to move back to the table. Leroy's cooperative behavior led to more requests to return to work. Not such a good deal from his point of view. The supervisor decided to be a little more assertive and said "Come on Leroy, you know you have to work," as he put his hands on Leroy's chair. Leroy looked up at the supervisor and yelled "No! No! I won't." Leroy has learned his lesson - no more cooperation. He continued to say NO!, even louder. The supervisor quickly decided that it would be a mistake to back down now and began to gradually drag the chair toward the table. Leroy immediately slammed both his arms to the chair, just missing the supervisor's hands. The supervisor jumped back and said, "OK, we can't make you work - but if you don't work, you won't get paid and you don't get a break." Leroy finally found a "SIGN" that worked and worked quickly - one that the supervisor clearly understood. He might have been a little confused about why he had to yell so loud and slam his arms repeatedly on the chair just to be heard but if that's what it took to get through to the supervisor then he would just have to do it. Now, I don't really believe that Leroy thought all these things, but I do believe that the above is a fair description of what he was being taught by the supervisor. He was learning that cooperation and task completion usually lead to more task assignments. He was learning that simple verbal complaints or requests for breaks had no effect. He learned very concretely that disruptive, aggressive behavior got him what he wanted. From Leroy's point of view it was the only way he could get what he wanted. 277 Immediately Leroy began to yell. He threw the bolt, breaking the window in front of his table. Then he began to cry and bite his hand and lips. The supemisor told Leroy to stop, He didn't. The other work adjustment supervisor called for help. It took four of the staff about 40 minutes to calm Leroy down, once they were able to hold him in a safe position on the floor. The staff of the ICF/MR facility were called and after Leroy had calmed down they took him back to the residential facility. LEROY'S SUPERVISOR MADE A SERIOUS MISTAKE. HIS `MESSAGE" TO LEROY WAS: "YOU MUST WORK" "I WILL IGNORE YOUR EFFORTS TO AVOID OR ESCAPE WORK" "THE ONLY THING THAT WORKS AROUND HERE IS TO DO WHAT I SAY" Leroy did in fact discover that simply asking to quit didn't work. He found out that minimal efforts to escape or avoid work, like moving away from the table, also didn't work. But Leroy has a long history that says to him: "ESCALATE" "START YELLING" "THROW THINGS" "BITE YOUR HAND" "HIT SOMEONE" These behaviors have always worked. In the long run, which Leroy does not understand or care much about, these behaviors also have had a serious negative impact on his life. He has been restrained, placed in seclusion, expelled from programs and even institutionalized because of them. These behaviors have been labeled as inappropriate, maladaptive, abnormal, even crazy. However, to Leroy they work in the short term and that is all that he understands now. Unless we make some important changes, the situation usually gets even worse. Leroy continues to hit his supervisor and the supervisor , in turn, continues to restrain Leroy, Quite naturally what little positive working relationship they did have is diminished. The supervisor pays less and less attention to Leroy unless of course he is being disruptive. Leroy is even less likely to have any positive experiences at work, which in turn makes it more likely that he will try to quit or leave. Over time he is less likely to even try the non-aggressive ways of quitting - 278 Handout l such as asking for a break, simply trying to walk away, etc. - these have never worked. Leroy learns to skip these steps and move directly to what does work - dangerous and disruptive behavior. You may be thinking that you would not find it rewarding to be restrained, to be expelled from a program. Please do not judge the situation from your point of view. You must learn to look at what is happening from Leroy's point of view. That is not the same thing as saying that Leroy's behavior is "CORRECT" or "RIGHT." It simply means that if we are to understand why Leroy does what he does, we must understand his point of view. What we think of as "NEGATIVE ATTENTION" may in fact be rewarding to people with long histories of challenging behavior. For example it is probably true that criticism, negative feedback, being yelled at, etc. is punishing to most people. whether it is true for most people is not the issue here. Leroy's point of view is all that should be considered if we are to understand him. LOOK AT THE SITUATION THROUGH HIS EYES: Leroy does not have a positive working relationship with anyone at the workshop. why should he care whether they are pleased with his behavior? why should he change his behavior based on their criticism? If Leroy behaves himself, follows instructions, does not cause trouble, etc., he will probably be ignored. At times he maybe praised for his appropriate behavior, but that is nothing compared to the immediate attention provided by the "crisis team" when he is disruptive. He becomes the center of attention, for the entire workshop. 279 IMPLICATIONS FOR CHANGE IN OUR SERVICES Look back at the "VICIOUS CYCLE" diagram, It is clear that based on the understanding of the cause(s) for behavior problems shown in the diagram that we can consider making changes in at least two major areas, if we are to help the person change hislher behavior. First, we can try to decrease the person's exposure to situations that are confusing frustrating, boring, frightening, etc. Second, we can assist them in learning alternative behaviors that also work for them, but that are not disruptive, dangerous or confusing. 280 Handout 6 Carl, Merle, Mary and the angry bus driver Carl works in a group home. Mary, who is Carl's supervisor was very concerned about his work performance. One of Carl's most important job responsibilities is to help the men who live in the home in preparing to go to work each morning. Carl works well with two of the men. They are ready for work on time each day. The third man, Merle is a different matter. At least once a week Merle is still eating breakfast and not even completely dressed when the bus comes. Mary has talked to Carl about this often, each time emphasizing how important it is for Merle to be ready for work in time to take the bus, The talks don't seem to have helped . . . twice in the last week the bus driver had to wait for Merle and once he was so late Carl had to call a taxi. Mary has developed a new plan that she thinks may work. Today she told Carl that if in the future Merle is late for the bus she will write an incident report and place it in his persomel file, If Carl gets more than one incident report over a two week period he will receive a written reprimand. If he receives more than three reprimands in a month he will be fired. However, if he helps Merle get ready for work on time every day for two weeks in a row she will arrange for him to have special time off from the job. Mary told Carl that she wished that these procedures weren't necessary, but that she felt like she had to implement them. QUESTION: "What is missing in the above story?" "Do you agree with Mary's approach to dealing with Carl's "problem" behavior?" You might not agree with Mary's choice of a punishment approach to changing Carl's behavior. You might be concerned that the procedures may not work and Merle will continue being late and Carl will be fired. However, there's an even more basic weakness to Mary's approach to dealing with the problem. She never tried to find out why Carl wasn't doing what he was supposed to do. She might have then been able to develop a plan to help Carl succeed, based on this information. TALKING WITH CARL AND OBSERVING THE MORNING ROUTINE MIGHT HAVE SHOWN: o That Carl was afraid of Merle and ignored him as much as possible to avoid the possibility of a fight. Because he ignored him, Merle sat around most of the morning without getting ready for work. o That Carl was not experienced in helping a person as severely disabled as Merle. He didn't know how to provide Merle with the physical and verbal cues he needed to wash, brush his teeth, get dressed, etc. o That one of the other men was taking up most of Carl's time each morning, Although he was working hard; Carl did not have the time to help both men. You are right if you are thinking there could have been many other reasons for Carl not being able to get Merle ready for the bus. However, it's pretty clear Mary's plan had nothing to do with any of them. 282 Handout 6 continued MARY HAD DEVELOPED A PLAN TO WAGE CARL'S BEHAVIOR. HER PLAN INVOLVED: o Punishing him if Merle was late by putting incident reports in his file which could lead to repr imands and eventually, to being fired. o Rewarding him for two weeks of good behavior (Merle not being late) by arranging for time off. Neither of these two consequences have anything directly to do with whatever is causing Carl's failure to help Merle. Mary's plan is based on the assumption that Carl will be afraid of losing his job and will therefore, do whatever is necessary to succeed. It might "WORK," but it has an even better chance of failing. Filing incident reports won't help Carl overcome his fear of Merle. The threat of losing his job won't teach Carl how to provide Merle with the types of cues and instructions that he might understand. Mary did not begin by trying to understand why Carl wasn't performing as he should, which would have then allowed her possibly to develop a plan to help him based on what she had learned. You might be thinking that none of the reasons listed above were true and that Carl just needed some extra "MOTIVATION" to do his job. This could be true, but we'll never know without asking the question, WHY? which Mary failed to do. 283 Handout 7 Kathy's Story - Success is in the eye of the beholder Kathy was 9 years old and labeled profoundly retarded. She has been living at a state institution for persons with mental retardation for the last nine months. Each morning one of the aides walked uthy across the grounds to her school program. She was scheduled to stay at school until the early afternoon. Kathy had lots of difficulty adjusting to the school program. During the first few months she often cried and tried to run out of the room. Her teacher, Mr. Richards, handled these situations by ignoring her crying, as much as possible, and gently redirecting her back to her desk if she attempted to run from the classroom. These procedures worked to reduce the crying and running away. During her sixth month at school she had only three tantrums and attempted to run away only once. However, Mr. Richards became concerned about a new behavior that presented even more serious problems. During her seventh month at the Center, Kathy began to vomit while at school. At first it only occurred infrequently but it gradually increased until she was throwing up every day. Some of the members of her team felt that she might be overly anxious about school and recommended that the physician prescribe a mild tranquilizer. The Doctor agreed with the request but the change in medication did nothing to decrease the vomiting behavior. The team then decided to suspend her from school for a month. l%is of course worked perfectly to decrease vomiting behavior at school. She couldn't throw up at school unless she was actually there! However, when Kathy returned to school she immediately returned to the vomiting behavior. Hoping to get a new perspective on the situation, the teacher asked the Center's behavior specialist, Roberta Fox to visit the classroom and see if she might be able to help. The first day Roberta visited the classroom Mr. Richards described what had been happening, about the results of the change in medication and the school suspension. AS she was finishing the description they heard a sound, looked up and saw Kathy throwing up at her desk. She and the student who sat in front of her were a mess. Mr. Richards immediately called for an aide to escort Kathy back to her cottage to be cleaned up and get a change of clothes. Ms. Fox asked the teacher if what she had just seen was typical of most days. Mr. Richards said yes, that almost every time Kathy threw up she had to be returned to her cottage and that often she did not return to school until the next day. Ms. Fox returned the next day with the following plan for decreasing Kathy's vomiting behavior. 285 At first it looked as though the plan might not work. Kathy threw up repeatedly during the first few days. In fact, on the third day she threw up, or at least tried to throw up 23 times. However, after the third day things began to improve. As the graph shows the frequency of the vomiting steadily decreased over the next 27 days and by the 30th day of the new procedures she went the entire day without vomiting. The graph below shows the frequency of vomiting over the 30 day period. She never threw up in class again, Mr. Richards and Roberta Fox had accomplished their objective. Kathy never threw up at school again. Do you consider this a success story? Let's look at the "SUCCESS" of the behavior plan from the point of view of all the people concerned. Mr. Richards -"It certainly was a success. The room smells nicer. Kathy looks better. Now maybe we can get on to school work." Ms. Fox -"I was more than happy to help Mr. Richards. We eliminated the target behavior faster than I thought we would. Maybe I can publish this as a research study." WHAT ABOUT KATHY?? Kathy cannot talk, but pretend for a minute that she could. How do you think she would answer the success questiod Suppose we were to interview her on the 30th day of the new behavior plan, the first time she went the whole day without throwing up - what is she going to say? "I JUST LOVE IT HERE!" "MY SCHOOL WORK IS VERY INTERESTING AND I AM LEARNING A LOT." OR "I STILL HATE IT HERE. I'D STILL RATHER LEAVE. I JUST DON'T TELL ANYONE ABOUT IT ANYMORE . . . . . Kathy is not likely to answer that the "BEHAVIOR INTERVENTION PLAN" was a success because nothing was done to help her with her "PROBLEM." 286 Handout 7 continued HER "PROBLEM" WAS THAT EITHER: 1. She dislikedwas afraid of the classroom setting 2. Nothing at school was more interesting or engaging than being back in the day room of her ward. The Behavior Plan did nothing to change these "PROBLEMS." The Behavior Plan was just that - a behavior plan. The teacher and Ms. Fox implemented a plan that was successful in making an improvement in Kathy's behavior but did nothing to help the basic reasons behind the problem behavior. Let's look at the situation more closely. 287 MS. FOX'S ANALYSIS OF THE SITUATION WAS IN A SENSE CORRECT. SHE SAW THAT: o Kathy either did not like the classroom or wanted to be back on her ward. o Mr. Richards had "accidentally" reinforced the vomiting behavior by letting her leave (escape) the classroom. o Over a period of weeks Kathy learned to vomit to leave the classroom. o Ignoring the vomiting (not allowing Kathy to leave) would eliminate the "ACCIDENTAL" reward. OVER A THIRTY DAY PERIOD KATHY GAW UP. SHE STOPPED VOMITING. There is no doubt that if people are placed in situations that they find unacceptable they will try to find a way to leave. They will often do whatever works - tantrums, aggression, even vomiting. There is also no doubt that if you are bigger than they are, if you are in control - you can make sure that nothing works. That's what they did to Kathy. At first I@thy was successful in running from the classroom, but then the teacher learned to beat her to the door. Later she had tantrums and sometimes was sent back to the ward to "CALM DOWN." The teacher was then instructed to ignore the tantrums. One day while she was having a tantrum she choked and threw up. The teacher immediately said "Take her back to the ward, clean her up. No more school today, she is too upset. " Kathy didn't understand much of what the teacher said but she did learn a new sign: VOMITING = "I WANTED TO LEAVE THE CLASS IMMEDIATELY." It wasn't at all clear to Kathy why the teacher required such an unusual sign, why he hadn't understood what Kathy meant by running away and crying both of which seemed to be more obvious to her. But she was happy for small favors and each day followed the teacher's "INSTRUCTIONS" by throwing up when she wanted to leave class. 288 Handout 7 continued Now of course I don't think that Kathy actually thought all these things out so logically and rationally but at the same time it is an accurate description of the important events and also makes it clear where the focus of our attention should be. We should be most concerned with answering the question - Why does Kathy want to leave the class? There is no arguing with the fact that vomiting behavior is "INAPPROPRIATE," that Kathy would be better off if she stopped doing it. In fact, if we really wanted to stop the vomiting quickly it would probably have been more efficient to teach her to exchange a token to leave class. Each day we could give her a blue poker chip. If she hands the chip to the teacher she is immediately allowed to leave the class - no questions asked. In far less that 30 days she would probably have learned the "exchange" value of the token and use it to leave class rather than resorting to vomiting. MANY OF YOU ARE PROBABLY THINKING: `Wait just a minute. ~thy may not be throwing up anymore, but now we have a different `problem. ' She spends very little time in school. Most days she hands in the token after only a few minutes and leaves school." Right! Now we have the "REAL" problem. The one we should have been most concerned with all along, that is - the school setting either frightens/disturbs her or offers her nothing more interestirghn and engaging than the day room back on the ward. Ms. Fox should have helped Kathy's teacher figure out what was frightening Kathy or how to interest her in at least some activities in the class. That would not have been an easy task. It was difficult to understand Kathy's likes and dislikes, except for the vomiting, and because of her limited experiences and profound disabilities her interests were fairly limited. But the fact is they made only minimal efforts in this direction - they were too focused on eliminating the vomiting behavior. 289 Resources Videotape: TITLE: A NEW WAY OF THINKING PRODUCER: Minnesota Governor's Planning Council on Developmental Disabilities & Minnesota UAP on Developmental Disabilities (1988) 300 Centennial Office Building, 658 Cedar Street St. Paul, Minnesota 55155 (612)296-4018 or (612)296-9962 TDD TITLE: AN ELEPHANT AT MOUSE PLACE PRODUCER: Kittelson & Leadholm Minnesota Governor's Planning Council on Developmental Disabilities (1990) 300 Centennial Office Building, 658 Cedar Street St. Paul, Minnesota 55155 (612)296-4018 or (612)296-9962 TDD TITLE : REGULAR LIVES PRODUCERS: Tom Doodwin & Gerardine Wurzburg (1988 ) Syracuse University WETA Educational Activities P.O. BOX 2626 Washington, D.C. 20013 291 Behavior Resources TITLE: TASK ANALYSIS, PROMPTING AND ERROR CORRECTION PRODUCER: Oregon Research Institute Tape 1: Task Analysis and Tape 4: Error Correction Research Press 2612 N. Mattis Avenue, Champaign, 1161821 (217) 352-3273 292