Transcript Challenging Behaviors in Clinical settings

Beth Ellen Davis MD MPH
Developmental Behavioral Pediatrics
March 2016
 3-8 year old with autism
 Clinical settings: therapy, doctors offices, mall
 Behavior: Disruptive, aggressive, self injurious, staff
injurious, traumatic behaviors
 Non productive visit, outing
“…result in self-injury, injury to others, cause
damage to the physical environment, and/or
interfere with the acquisition of new skills, and /or
socially isolate the learner.”
Doss &Reichle, 1991
 Aggression
 Self-Injury
 Hyperactivity
 Mood problems
 Obsessive-compulsive behaviors
 Emotional reactivity
 Oppositional Defiant Disorder, Conduct Disorder
 Video clip from you tube, autism speaks challenging
behaviors Part 1/10
 Under the umbrella of Disruptive Behaviors
 May be typical at certain developmental stages (two
year old tantrums, adolescent rebellion), if limited in
duration and severity.
 Types




Impulsive (biting, hitting)
Emotional reactivity (increased arousal)
Operant (learned, to get desired response)
Proactive (premeditated violence, stealing)
 3% - 9% of typical children and youth
 Up to 50% of children with Autistic Disorder
 Lack of communication





skills
Poor self regulation
Difficulty with transitions
Avoidance and anxiety
Sensory overload
Poor understanding of
effect on others
(Theory of Mind)
 Video You tube: Autism speaks challenging behaviors,
Part 2/10
 Avoid or escape undesired




tasks or outcomes
Gain attention
Gain access to desired
outcomes (objects, activities)
Self stim (automatic)
Pain? Poor sleep? Constipation?
A ntecedent : Understand the trigger,
events or environment before the behavior
B ehavior: describe the behavior, the associated
circumstances (FINDS) and the “function”* of the
behavior
C onsequences: what happens after the behavior,
what reinforces the behavior? What does the child
“get” out of the behavior?
**I am not going to lie, this is HARD sometimes!
 Behavior is ……..
 Frequency
 Intensity
 Number of associated circumstances
 Duration
 Settings
 A screening tool to identify FUNCTION of behavior
 Affirmative answers results in
 Likelihood of behavior occurring for:
 Attention getting
 Escape
 Sensory stimulation
 Pain attenuation (self injury)
 See handout
 A school tool!
 Kids on IEPs with challenging behaviors, should have
an FBA (esp following a short term suspension, if
disrupting a learning environment, or violating rules
or safety).
 BIP is a written specific purposeful and organized plan
that describes positive behavioral interventions,
reactive strategies, and evaluation.
 Parents
 Reward good behavior
 Have consequences for undesired behavior
 PRACTICE!
 Bring distracters, have head phones/DVDs
 Seek communication (PECS “first/then” boards)
 Decide what your restraint strategy is, or what works in
the park? (stroller with 5 point ?)
 What are signs that a “meltdown” is rumbling? Can you
avert a full blown outburst?
 Professionals
 Protocol
 environment (allow stroller in room, minimize stimuli)
 Procedures (model activity with doll, touch distant parts of body )
 Prepare
 Ask parents what works (what doesn’t)
 1st visit of the day, no wait, no vitals?,
 Special toy to play with only in setting
 Back up toy (DVD?)
 Schedule practice visits without tasks
 BE CLEAR
 “sit here please”
 use PECS First/Then boards
 Crisis plan -“Call for Dr Strong-arm?”
 Pain: ear infection, toothache, foreign body in foot,








headache, sinus problems, sprain
Itching: eczema, pinworm
Medication related?
In adequate or inefficient sleep? OSA?
GI: constipation, food sensitivities (meal related?), GE
reflux? Bloating or nausea? Motion sickness?
New onset anxiety or depression?
Are environmental demands too much
Is child being overwhelmed by noise, emotions?
Seizure related?
 Adapt stroller with 5 point restraint. Use strollers for older
children than only pre-ambulatory infants. What is used
on the school bus?
 Weighted blankets
Remember, all individuals and their families should feel safe
and supported and be able to live a healthy life filled with
purpose, dignity, choices, and happiness.
 Multimodal
 Developmental assessment
 Environmental assessment
 Functional behavioral assessment
 Parenting difficult behaviors –skill building
 Educational supports
 Communication supports
 Psychopharmacotherapy…..
 Stimulants
 SSRI
 Alpha- agonists
 Atypical neuroleptics
 Aggression
 See handout
 Examples: head banging, face slapping, self biting, eye
poking, lip and finger chewing, limb banging
 Incidence inversely related with IQ
 Prevalence 3% community; 15% institution
 80% is Operant (learned behavior to get desired response)
 1st line treatment is behavioral modification
 Medication : atypical neuroleptic
 Running away
 In ASD, 49% of a large study, reported “running off”
25% went “missing” long enough for concern
Of those missing with concern
25% at risk for drowning
65% at risk for traffic danger
Risk increased with severity of ASD
What to do?
Bracelet, notify local police, discuss in neighborhood. Let
school and day care and baby sitters know this is a risk.
Supervise. Discuss.
 Autism Speaks Toolkit: Challenging Behaviors
 You Tube “Challenging Behaviors”