Is it Sensory or Behavior? Understanding Challenging Behavior

Tara: Thank you for having me. As occupational therapists, how many times have you guys heard the question, "Is it sensory or behavior?" I cannot even count the number of times I have heard this. This is why I put together this training to help you better understand challenging behavior. I am an occupational therapist and work in the clinic, schools, homes, mostly working with children with autism or some type of challenging behavior. I do a lot of consultation in the schools and work with teams on how to help and support individuals who are having challenging behavior. Many situations I am going to talk to you about are related to schools, but you can also apply them in the home, clinic, or anywhere you are working with children or individuals with challenging behavior.

Introduction

This is one of my favorite quotes.

Kids have to want to be with you. They have to want to be at school and in your sessions. If they are not happy, they are not learning. We always start by making sure that kids are happy and they want to be there. I also like this quote.

If a child does not know how to behave, what do we do? We often punish or take away something, like recess. Instead, we need to teach behavior. I often tell teams, if a child knew what to do, they would be doing it. Children with challenging behavior do not like it any more than adults; they just do not know what else to do. We have to think about challenging behavior as a teachable moment.

What Does the Research Say? (Dunlap, 2006)

Presence and Impact

When children with significant problems are neither identified in a timely way nor given appropriate education and treatment, their problems tend to be long-lasting, requiring more intensive services and resources over time. Moreover, when the challenging behavior of young children is not addressed in an appropriate and timely way, the future likelihood increases for poor academic outcomes, peer rejection, adult mental health concerns, and adverse effects on their families, their service providers, and their communities. Although some systems and tools for early identification of children with challenging behaviors are available, the actual identification of these children and the provision of appropriate services are very low.

Children, who exhibit challenging behaviors, are considered at risk for academic failure, delinquency, drop out, gang membership, and adult incarceration. We have to find ways to address challenging behavior. Ten to fifteen percent of all typically developing preschool children have mild to moderate levels of behavior problems. In a class of 20 kids, that is two kids that have challenging behavior. When children are not identified in a timely way, their problems last longer and are more intense. We also know that tools are limited to address challenging behavior.

Prevention

Children, who access mental and physical care, are less likely to have behavioral and social problems. We also know that a nurturing positive parent is associated with reduced challenging behavior. Finally, high quality, early education is associated with fewer behavior problems and the development of social competence.

I am working with a school right now that has a school-wide program that is targeting quality in classrooms. I informed that team that quality classrooms in early childhood provide a direct impact on how these kids are going to behave when they are older. As occupational therapists, we play an important role. We need to help teachers understand what a quality classroom is.

Intervention

• Interventions based on a functional assessment of the relation between the challenging behaviors and the child’s environment are effective for reducing challenging behaviors of young children.
• Teaching procedures have been demonstrated to be effective in developing children’s skills and reducing challenging behaviors.
• Interventions involving alterations to features of the child’s activities and the child’s social and physical environment have been demonstrated to reduce challenging behaviors.
• Multicomponent implemented over time and across multiple relevant environments can produce durable, generalized increases in prosocial behavior and reductions in challenging behaviors.
• Family involvement in the planning and implementation of interventions facilitates durable reductions in challenging behaviors of young children.

Interventions, based on functional assessment between the behavior and environment, has research behind that. We are going to explore that more today. Teaching procedures have been demonstrated to be effective, in reducing challenging behaviors. Most challenging behavior in the class occurs when a procedure is not in place. Interventions involving alterations to the features of the child's activities and the child's social and physical environment have been demonstrated to reduce challenging behaviors. Looking at the environment is a big piece. Multicomponent interventions over time can also reduce challenging behaviors. Finally, in order to change behavior, we have to involve the family. When they are at school or are in therapy, they are only there for a short amount of time, and then they go back to be with family. We need to make sure that we are including them in our planning.

Common Pitfalls

I am going to talk just a little bit about some pitfalls that I see. I come from more of a behavioral background, while one of my colleagues comes from more of a sensory background. We worked on these steps together to find common ground and use a common language.

Behavioral Pitfalls

• Rewards used as bribery instead of positive reinforcement
• Rewards not given enough or too predictable
• Rewards not meaningful to the child/student
• Time outs/consequences not used appropriately and too often
• We often reinforce the “wrong” behavior
• Does not take into account the sensory preferences of the child

These are some pitfalls that I see from a behavioral background. People think they are rewarding, but they are often bribing, instead of using positive reinforcement. I see rewards not given enough, or they are too predictable. An example is that if they are good all week, they can have 30 minutes on the computer. Another problem is that rewards are not meaningful. A classroom may have a reward system set up where all the kids get stickers. There might be one kid that does not like stickers. Time outs and consequences are often not used appropriately or are used too often. In one of my classrooms, there was a child that was in a time out five times a day. The teacher put him in a time out when he did not do his math. It was not working as it was not changing his behavior. We are using different strategies, but we are not really reflecting on whether it is working or not. We often reinforce the wrong behavior. For example, a kid tears up a worksheet, we put him in time out, and we reinforce that behavior.

We do not take in account the sensory preferences of the child. We often look from a behavioral standpoint without looking at the sensory needs of the child. We need to use some common language, but it can be really hard.

Sensory Pitfalls

• Implement sensory strategies in place without thinking about "the why"
• Begin with sensory strategies before looking at environmental changes
• Sensory strategies are not systematically implemented
• Sensory strategies only implemented during OT sessions
• The plan doesn’t change when the strategies do not work
• Often used as a way to avoid addressing other environmental factors

I often see people implementing sensory strategies without thinking about the why. Sometimes, I feel like we are the handwriting and fidget people. We will get a request for a weighted blanket or vest to help them sit in circle time. Instead of really looking at behavior and discovering the why, we throw strategies at them. We look at sensory strategies before making environmental changes. Teachers and parents often say a child has sensory issues. Looking at the classrooms, I often think I would have sensory issues too. They need structure, predictability, and reinforcement, and sensory strategies are not systematically implemented. The strategies are implemented in OT, but they are not used elsewhere. If the strategies do not work, what are we going to do next or how are we going to change it? Finally, it is often used in a way to avoid addressing other environmental factors. Often the problem is attributed to the child and not the environment. In order to change behavior, we have to change the environment.

How Do We Work Together?

Here are ways that we can work together.

• We have to take our judgment out of the behavior.
• Behavior is communication & serves a purpose.
• The behavior continues because it is reinforced.
• Teach an alternative skill.
• Address environmental concerns.

We have to take the judgment out of the behavior and see it for what it is. We have to think of behavior as communication that serves a purpose. No matter what framework you are coming from, we have to think that there is a reason this child is doing this behavior. It might be a sensory or communication reason. Behavior also continues because it is reinforced. Even if we think that we are punishing the child by putting them in a time out, by taking away a recess, or by taking away a toy, if the behavior keeps happening, we are reinforcing that behavior. What are they getting out of this if they continue to do the behaviors? We have to look at teaching alternative skills. An example might be a child hitting their peers. Thinking about the why, what else do you want him to do at this time? Instead of worrying about the hitting, let's worry about the replacement behavior. We also have to look at the environment.

Positive Behavioral Supports

I am sure you have heard of this term before. It is research-based and a bridge between the two approaches. It is a way we can combine our approaches to impact challenging behavior. It focuses on data-based decisions because, with everything we do now, we need to use data. We also need to make sure that it is working. It focuses on the environment as well as the child. It focuses on replacement skills that we are going to teach. There are some great resources on pbis.org.

Challenging Behavior

Challenging behavior is any repeated pattern of behavior, or perception of behavior, that interferes with or is at risk of interfering with optimal learning or engagement in pro-social interactions with peers and adults (Smith and Fox 2003). In my mind, challenging behavior is anything that impacts that child where they cannot do what they need to do. They cannot perform their occupations of daily living. We have to think about behavior as information. We are not going to think about behavior as good or bad. Instead of good or bad, I say expected or unexpected. I learned that term from Michelle Garcia Winters. We are thinking about behavior as information. If you think about it as information, instead of good or bad, we look at situations differently. For example, for the child that tears up his math worksheet and gets put into a time out, he does not have to do any more math. In our opinion, that might be bad behavior, but for that kid, it was good behavior. It worked for him. The best teachers and therapists are ones who change what they are doing in order to change behavior. The hardest teachers to work with are the ones who are not very flexible. They expect the children to change and adapt. However, if the behavior is not changing, I have to do something different. This can be a big pill for people to swallow. We are going to go through the steps of putting together a plan for challenging behavior.

1. Identify the Behavior

The first step is to identify the behavior. This can seem a lot easier than what it is. We do an internship every year. We used to just blow this part off, but once we started getting down to it, people have a hard time with this. You have to describe the behavior in a way that anybody would understand, and you have to count and label that behavior. You need to avoid words such as meltdown, aggressive, disengaged, hyperactive, or inattentive because those are not measurable. A meltdown looks very different for different people. Instead, we need to describe the behavior. "He rips his paper." I can look at that one. He does not follow a direction after three seconds. Do you see how that would be very measurable? I would measure every time an instruction is given and see if he responds within three seconds. If he does not, I am going to address that behavior. Those would be behaviors that I could address and measure.

The stranger test is that anybody could take data on that behavior. You also only want to only pick two to three behavior. You do not need to pick every single behavior that happens because it would be very overwhelming. I have had people do this in many different ways. Some have picked only the most harmful behaviors, like running away or running out of the classroom. Other examples are hitting or biting. I have also started with the initial behavior to look for patterns. Finally, I have had people look for the easiest behavior to change. They pick the behavior where they feel they could make a difference in the shortest time.

Another important concept is to not form hypotheses yet. Often teachers will say, "He refuses to do his work because he is lazy." The teacher is already hypothesizing about the behavior and judging the behavior versus seeing it objectively as a way to communicate. At this point, all I want to know is exactly what the child is doing. I am going to hypothesize later after I have gathered objective information

Example 1

When transitioning from breakfast to rug time, Jacob will run around the room until the teacher physically stops him. When she stops him, he starts hitting her and kicking her until she takes him into the hallway, sits him down, and makes him wait. 

What would you describe as the behavior? I would say Jacob running around the room and Jacob hitting and kicking are the behaviors. There are many questions to ask. Does he run around the room at certain times? Yes, he runs around the room during rug time. That is the behavior that I am going to be addressing. I might also address the hitting. I need to start by describing the behavior.