PositiveBehaviourSupportforChildrenwith

DownSyndrome

SusanFawcett,M.Sc.,RSLP,

PhDCandidate

“FromGoodtoGreat”

October27,2017

Outline

• Whybehaviour isaconcern• Behavioural characteristicsofchildrenwithDownsyndrome• Contextofchild:positivebehaviour support• Contextofproblembehaviour• Functionsofbehaviour (or:learntobeadetective!)• Practiceactivitywithvideos

• Strategies!

WhyProblemBehaviour isaConcernWhyworryifyourchildisexhibitingsomeproblematicbehaviour?

• Itlikelywon’tgoawayovertime,andmayworsen• Behavioural issuesinchildhoodpredictthoseinadulthood

• Problembehaviour maynegativelyimpact:• Safety• Learning• Socialacceptance&inclusion• Familyrelationships• Placementsinclassroomsorworksettings• Overallqualityoflife

Behavioural IssuesinDownSyndrome• Asignificantproportion(20-30%)ofchildrenwithDShavecomorbiddiagnosessuchasautism&/orbehaviour disorders(Caponeetal.2006)• Attention-deficithyperactivitydisorder• Obsessivecompulsivedisorder• Anxiety(includingselectivemutism)

DSM-5CriteriaforAutism• AutismSpectrumDisorderdiagnosis• Deficitsinsocialinteraction• Restrictedandrepetitivepatternsofbehaviour orinterests

• Allsymptomspresentinearlychildhood• Symptomslimiteverydayfunctioning

RedFlagsforAutisminChildrenwithDownsyndrome• Nointerestincommunicatingwithothers(i.e.socialindifference/withdrawal)

• Generallackofinterestinpeople• Nouseofgestures• Regressionincognitive,language,and/orsocialabilities• Totallackofverbalcommunication,coupledwithnoattemptsatusingothermodes

• Treatingpeopleasinanimateobjectsi.e.usingsomeone’shandtogetdesiredobject

• ‘Odd’behaviours sometimesassociatedwithautisme.g.smellingobjectsorself-injuriousbehaviours

WhenProblemBehaviour isJustProblemBehaviour!• Amongthosewithoutasecondarydiagnosis,manymaystillstrugglewithbehaviour enoughthatitimpedestheirabilitytolearnorparticipatefullyinactivitiesordailylife• Inotherwords,thebehaviour “getsintheway”

NeurologicalUnderpinningsofProblemBehaviour inDS1. Reducedabilitytoprocessinformation,particularlyauditory

information2. Decreasedlevelsofintrinsicmotivation3. Problemswithexecutivefunctioning,i.e.,maybemoreimpulsive,

andmaylackabilitytoplantheirbehaviour orthinkaheadoftimeaboutitsconsequences

4. Memoryproblems:reducedencodingandconsolidationofnewinformation

5. Hyper-awarenessofotherpeople

The“HamEffect”• Duringcognitive“work,”childrenwithDSshow:• Lowerlevelsoftaskpersistence

• Higherlevelsof“off-task”behaviours• Overuseofburgeoningsocial

skills• Partytricks

Inotherwords,the“hameffect”hasbeendocumentedintheresearchliterature!(Fidler,2005;Pitcairn&Wishart,1994;Wishart,1993)

Behavioural CharacteristicsofChildrenwithDownsyndrome• “ChildrenwithDSmayalso‘overuse’theirsocialskillstocompensateforotherweakerdomainsoffunctioning”(Fidler 2005)• “MAY????”

TheImportanceofContext

• Contextsurroundingthechild

PositiveBehaviour Support

• Scientific,values-basedapproachtotheassessmentandinterventionassociatedwithproblembehaviour• Basedonprinciplesofappliedbehaviour analysis• AprofessionalusingPBSwillworkcollaborativelywith thewholecontextsurroundingthechild:peopleandenvironments(home,school,andcommunity)

TheImportanceofContext• Contextsurroundingtheproblembehaviour

Amy is a delightful, playful 4-year-old girl with Down syndrome. She lives with her mum, dad, and 7-year-old sister. She loves playing with her dog, watching Paw Patrol and dancing around the living room with her sister and dad. She is in good health overall, but is a picky eater and on some days, she eats very little.

Lately, around bedtime, she has been engaging more and more frequently in some problematic behaviour. When her mum tells her it’s time to put on her pajamas, Amy begins to whine, saying, “No bed!” If her mother persists, she starts giggling and rolling around on the floor. Mum has to then try to wrangle her flailing body into bed, which does not always work because doing this often hurts her back. If Mum leaves Amy, she remains quiet in her room until she falls asleep on the floor in her clothes, but this can take a couple of hours. This is all more likely to happen on days when Dad is working late.

Settingevent Antecedent Problembehaviour

Consequence(FUNCTION)

Context

• Wecan’tjustlookattheproblembehaviour alone.Weneedtolookatwhathappensaroundit;at4differentpointsintime:1. Beforeorsimultaneouslywithproblembehaviour2. Immediatelybeforeproblembehaviour3. Problembehaviour itself4. Rightafterproblembehaviour

SettingEvents• =Beforeoratthesametimeasproblembehaviour• Theseareevents,situations,orphysical/emotionalstatesthat,whenpresent,maketheproblembehaviour MORElikelytooccur• CommononesforpeoplewithDS:physicalillness,fatigue,hunger,buzzinglights,toomuchnoise,lackofpeer/parentattention,behavioural history

(Mirenda,2014)

Antecedents• =Immediatelybeforeproblembehaviour• Canbetrickytofigureout,but:• Askyourself:“What’stheonethingIcandotomaketheproblembehaviour occur?”

• Anothernameforthisisthetrigger

ProblemBehaviours

• =Problembehaviour itself• “Operationallydefine”thebehaviour;i.e.giveacleardescriptionofwhatthebehaviour lookslike,includingintensityandfrequency• “aggressive”vs “hits,bitesandsometimeskickspeersapproximately3timesperday”• “doesn’tlisten”vs “doesnotrespondtoinstructionswithin30seconds”

Consequences• =Immediatelyafterproblembehaviour• NeedtocloselyexamineEXACTLYwhathappensatthispoint• Itmaysurpriseyou;itmaybedifferentthantheconsequenceyouthoughtyouweregiving

• Mostimportantpieceofthe4-termcontingencyforassessmentbecauseitallowsyoutodeterminetheFUNCTIONofthebehaviour

Functionsofbehaviour

Whatthebehaviour “lookslike”isnotreallyallthatimportanttothisprocess…youmustfigureoutWHYthebehaviour isoccurring

Functionsofbehaviour

• EVERYbehaviour hasareasonbehindit• Contrarytopopularbelief,behaviours rarely“comeoutofnowhere”• Evenifthebehaviour doesn’tmakesensetoyou,forthechildwithDS,thebehaviour islogical andpurposeful

Thisisgoodnews!!

Functionsofbehaviour

• Evenbetternews:thereasonsforbehaviour arelimitedinnumber!• Thereareonly4:1. Attention2. Escape3. Tangible4. Automaticreinforcement

Attention• “Mum,lookatme!”• Problembehaviour oftenoccursbecausethechildistryingtogetattention• Thiscanbepositiveattention,ORnegativeattention!Whenyoudon’tgetalotofattentionfromotherkidsatschool,anykindofattentionwilldo

• Examples:agirlstartssingingloudlyassoonasherEAgoesacrosstheroomtohelpanotherstudent&theEAcomesrushingbackover;aboyunravelsthetoiletpaperalloverthewashroominordertogetareactionfromhispeers

Escape• “Idon’twanttodothis”/“thisistoohard”• Verycommonforchildrentobehaveproblematicallyto“getoutof”something• Thiscouldbeacompleteendtoanon-preferredactivity,orjustadelay

• ThisisalsothefunctionatplayduringthedreadedTRANSITION!!

• Examples:agirlcrawlsunderthetableduringherspeechtherapysession&doesn’tcomeoutfor10minutes;aboysquirmsandwhinesduringcircletimeandhisteachergiveshimatime-out

Tangible• “IwantOreos/iPad/TV/dollhouse/abikeride/stickers/goldfishcrackers/togotothepark!!!”(NOW!)

• Canhappenwhenachildwantssomethingthatisphysicallyinaccessible,currentlyunavailable,ortakenaway

• Aboygruntsandyellswhilelookingathislunchbag untilsomeonegivesittohim;agirlbegsandwhinesuntilherdadtakeshertothepark

AutomaticReinforcement

• Notasociallymediatedfunctionlikeescape,attentionortangible• Sometimesreferredtoas“self-stimulatory”behaviours• NOTjust“anautismthing”• MayhelpapersonfeelmorecalmORmoreawake• Wealldothese…

Amy’s4-termcontingency

NotenoughtoeatDadisworkinglate

Demand:“Timeto

putonyourPJs!”

Whines;saysno;giggles;rolls

aroundonthefloor

Sitsinroom;doesnotgoto

bed(ESCAPE)

Afewcaveats…• Functionisnotalwayseasytofigureout

• Usuallymorethanoneatplay,butgenerallyaprimaryculprit

• Ifyourchildisengaginginsevereproblembehaviour,thefollowingstrategiesmaynothelp• Propertydestruction• Lengthyorveryintensetantrums• Runningaway• Injurytowardsselforothers

• Youwillneedtogetprofessionalhelp fromaBoardCertifiedBehaviour Analyst(BehaviouralConsultant)

Strategies

• Besttohavestrategiesthataddresseachoneofthe4contextualplacesintime• Thiswillresultinthemosteffectiveplan

• Strategiescanbeveryindividualized,buthere,wewillonlytalkaboutonesthataregenerallyeffective

Strategies:Settingevents

• Ensureassessmentandtreatmentiscompletedforallmedicalissues• Duringtimeswhenmedicalissuesareatplay,reduceexpectations!• WorkaroundtheSE:ex.,ifpoorsleep,thenstartthechild’sdayatschoolwithaquicknap;givemorerewardsandbreaks

• Workareasathomeandschoolshouldideallybefreeofdistractions,excessnoise/people• Optimalhealthforlearningwithproperdietandexercise

Strategies:AntecedentsALOTofproblembehaviours canbepreventedfromoccurringinthefirstplace• Providechoices• Useeffectiverequests• Enhancepredictability(usevisualschedulesorfirst-thenboards)• Incorporatepreferencesintodifficultactivitiesorroutines

(Dunlapetal.,2013;Mirenda,2014)

ProvideChoicesTypesofchoices:n Task/Activity: “Wouldyouliketoworkonreadingorcounting?”nMaterials:“Wouldyouliketouseacoloured penciloracrayontodrawwith?”

nHowmuchtodo:“Thismanysightwords(thinstack)orthismanysightwords(thickstack)?”

nHowlongtodoit:Youcanworkfor5minutesor10minutes.Yourchoice.”

n Sequence:“Whatdoyouwanttodofirst:Takeabathorbrushyourteeth?”

nRewardaftertaskoractivitycompletion:”Afterpickingupyourtoys,youcanearntimeoniPadorasnack.Whatwouldyouliketoearn?”

EffectiveRequestsGuidelines:1. Firm,confident,calmtoneofvoiceinanappropriate

volume2. Usestatements(notquestions)&simplelanguage3. Makeonerequestatatime4. Bespecific5. Makerealisticrequests(appropriateforchild’sage)

“Shoeson!”NOT“Couldyoupleaseputyourshoesonformommy?”

VisualSupportstoEnhancePredictability

IncorporatingPreferences

IncorporatingPreferences:Silly-ology• Makeyourinteractionsmorefun!

• Examplesofsillinessabound:• Makingstrangefacesornoises• Pretendingthereisa“closecall”

(“Phew!!”)• Unexpectedsingingordancing• Pretendnapping,sneezingor

mouth-burning• Puttingrandomobjectsonyour

head• Pretendingtoeatinediblethings• Anykindofover-exaggerated

action

Whatmakesyourchildlaugh?

Strategies:Antecedents• Transitions – theyDON’Thavetobe

SCARY!!!

Strategies:Antecedents

• Transitions!• Incorporateaslightlypreferredactivityorobjectasyougofromapreferredactivitytoanon-preferredone• Behavioural momentum• Countdown(makeitvisual!)

Strategies:Behaviours

• Teachthechildamessagetosaythatservesthesamefunctionastheproblembehaviour• Attention:“Mum,look!”or“Iwanttositwithyou”• Escape:“Ineedabreak”or“Iwanthelp”• Tangible:“Iwant___,please”• Automatic:“Ineedtowakeup”or“Ineedtocalmdown”

Strategies:Behaviours• Teachnewskillsthatwillhelpthechildcopebetterinavarietyofsettings• Academicskills• Socialskills(e.g.athome:programtoimprovesiblinginteractions)• Independentplayskills

Strategies:Consequences

• Don’tinadvertentlyrewardproblembehaviour withwhatyourchildwants!(keepinmindfunctionhere)• Example:Ifyourchildislookingforattention,donotgiveitasaconsequence• Tip:Negativeattentionisjustaspowerfulaspositiveattention

Strategies:Consequences

• Consequencesfordesiredbehaviours:Rewarddesiredbehaviour!Immediatelyandenthusiastically

Praise• Guidelinesoncontentanddelivery:

• Usespecificlanguage(“Wow!Youputyourcoaton!”vs.“Goodjob!”)• Childrenneedtoknowexactlywhatitwasthattheydorightsothattheycandoitagaininthefuture

• Useanenthusiastic/upbeattoneofvoice(orwhatevertonethechildprefers)

• Smile!• Usevariedwordingtoavoidsatiation/boredom• Couplewithnon-verbalpraise,too(fistbumps,high5s,clapping)

• Aim=5:1ratio(praise:corrections)

ExamplesofPraise:Colouring Activity• Ilovethatcolour!• Oh,thatlookswonderful.• Youaretryingsohard!• The____looksgreat!• Youaresocreative.• Whatagreatcolour topickforthat___!• Youaresogoodatcolouring.• Canyouteachmehowtodoit?• Wow,youaredoingagreatjobstayinginsidethelines.• Thanksforaskingsonicelyforthatcrayon!• Youaregettingsomuchbetteratcolouring.• Wow!Youarealmostdonethe___!

Take-homemessages

• Beadetectivewithregardtoproblembehaviour:youneedtodigintothecontextsurroundingit,andyoumustfigureoutthereasonforitsoccurrence!• Putmostofyoureffortintopreventingproblembehaviour fromoccurringinthefirstplace• Catchyourkidsbeinggoodandrewardthemforit!

PreventativeFamilyCentered-PositiveBehaviour SupportforFamiliesofChildrenwithDownSyndrome• Dissertationproject;examiningeffectivenessof16weeksparenttraining• Pilotstudyinspringresultedindecreasedproblembehaviour

• Intheprocessofrecruiting12familieswithchildrenaged3to8toparticipate;pleasecontactDSRFifyouorsomeoneyouknowinthelowermainlandofBCmightbeinterested

susan@dsrf.org