Challenging Behaviour and Mental Health Dr Dominique Newsome Specialist Clinical Psychologist

Outline Introduction & ground rules Defining “challenging behaviour” How we learn behaviour The function of behaviour Communication exercise Vulnerability factors CB and mental health Break Understanding challenging behaviour Describing behaviour S.T.A.R approach Managing challenging behaviour Supporting communication Feedback

When does behaviour become “Challenging”? What do we mean by “challenging behaviour” ? Get into pairs and take a few minutes to think about it.

A formal definition “ Culturally abnormal behaviour, of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of , or result in the person being denied access to, ordinary community facilities” (Emerson 1995).

Types of challenging behaviour… Aggression- verbal and physical Withdrawal Inappropriate sexual behaviour Self –injurious behaviour Refusing to co-operate

How we learn behaviour We are all shaped by our environment. How we behave is influenced by the way our environment responds to us. In other words how we behave depends on what we “get out” of what we are doing.

Reinforcement Positive Reinforcer Something is added as a consequence of a behaviour that will increase the chance of the behaviour happening again e.g. Receiving praise when you have done something well. Negative Reinforcer Something is taken away as a consequence to the behaviour which will increase the chance that it happens again e.g. Removing a child from class when they have hit a peer

Functions of behaviour Research has shown that a majority of behaviour happens for the following reasons : i) Gain something (e.g. computer, food etc.). ii) To gain/ maintain social interaction. iii) Sensory stimulation. iv) To avoid or escape an aversive situation. A behaviour can service different functions at different times.

Communication Challenging behaviour can be thought of as a form of non-verbal communication. If a person lacks the cognitive & language skills needed to express their needs verbally they may come to rely on their behaviour to communicate their needs. Communication exercise

Why do children become challenging? Social environment (isolation, lack of meaningful activity/ control/ choice/ structure/ predictability) Emotional (anxious, sad, confused) & Cognitive (poor language skills & comprehension, poor working memory) Factors Functional skills (Can your child physically do what they have been asked to do? Vulnerability factors History/ trauma (Recent loss or change, difficult experiences Physical environment (busy, noisy, bright, hot) Health (pain, epilepsy, illness)

So it may be understandable that challenging behaviour is the main form of communication that a child diagnosed with learning disabilities and neurodevelopmental disorders can use when experiencing a mental illnesses. Today we will focus in particular on:- Anxiety Depression

Anxiety The world can be unpredictable and confusing. Our minds can make up lots of different outcomes to an event. For children diagnosed with learning disabilities and neurodevelopmental conditions this is magnified. Consequently it is not surprising that 84% of children with ASD meet criteria for at least one anxiety disorder (Muris, 1998). Anxiety is when your child may perceive a threat that presents no harm to them. Yet, they experience an unpleasant feeling of dread about the anticipated event which interferes with your child’s ability to function.

Anxiety and CB So why would my child’s behaviour become challenging if they are anxious? Everyone has a natural survival mechanism when faced with a threat… Fight e.g. Aggression Flight e.g. Withdrawal Freeze e.g. Refusal to cooperate

Depression All children will feel sad at some point in their lives but for a child experiencing depression the sadness lasts longer and can affect different aspects of their lives (e.g. socially, academically etc.) Your child may experience low mood for a number of reasons:- Bereavement loss of teaching assistant or favorite teacher sibling leaving home parental separation moving home/school change in routine pain or illness

Depression and CB There are some key signs that you may notice:- Sudden or gradual changes in usual behaviour- disruptive at school Outbursts of anger, irritable, destructiveness or self- harm Loss of interest- in school, play or extra-curricular activities Loss of skills, motivation and low energy Loss of ability or willingness to communicate Poor concentration Loss of bowel or bladder control Physical illness- stomach pains, aches, pains, headaches, frequent cold symptoms, diarrhoea, vomiting Seeking reassurance Low self-esteem and confidence; focusing on problems and faults; being self-critical

If we start to see behaviour as a form of communication then by thinking about why someone is acting the way they are, and looking at patterns of behaviour, we can gain clues as to how to manage it…

Time for a break…

Problem behaviour checklist What exactly happens? How bad do you feel the problem is right now (0-10)? When does it happen? When doesn’t it happen? Who does it happen with? Who doesn’t it happen with? How often does it happen? When does it happen less? How long does it go on for? When does it go on for less time?

S.T.A.R Setting – Where did the behaviour occur? Was it crowded/ noisy? Trigger – What was happening immediately before the behaviour? Action – What was the behaviour exactly? Response – How did you or others respond?

Describing challenging behaviour exercise Clearly define the behaviour you wish to address. If there are more than one, identify which one is most troubling. Using the Behaviour Checklist, take 5 minutes to answer the questions about this behaviour. What may be the triggers. Think about the vulnerability factors. Do you think it could be a Mental illness? What responses are given for the behaviour. Think about positive and negative reinforcement Set goals.

What are your thoughts about this example… Sarah is a 10 year old girl with a learning disability. On arrival home from school she always has some juice and 2 biscuits. She always asks for more and will begin to shout and sometimes hit her head when they are put away. Sometimes her mother ignores Sarah, sometimes she shouts back and sometimes she gives in and allows Sarah to have more biscuits.

Managing challenging behaviour General principles: Environmental changes It may not be possible for a child to change & therefore we may need to adapt the environment to suit the child in order to remove triggers. e.g.- If you know a trip to the supermarket triggers challenging behaviour can you avoid placing your child in that situation in the first place? Consistency This is a key principle in managing challenging behaviour. Have an agreed strategy for managing challenging behaviour & ensure that everyone follows this each time. This will help the child understand what is expected of them & the consequences. Rewards Reward desired / “good” behaviour. Rewards are more effective than punishments. Rewards should be immediate so your child links them to the behaviour. Think about what is rewarding for your child- your idea of a reward might be very different!

Managing challenging behaviour Punishment and Boundaries Punishment is generally ineffective. It is important that we model to our children that we can solve problems & deal with difficult feelings without shouting, “losing control” etc. But ALL children need firm & consistent boundaries. This can actually be reassuring for children as they know what’s expected of them. Whilst we need to be tolerant of some autistic behaviours, autism itself should not be an excuse for “bad” behaviour. Expectations Have realistic expectations for your child. Tasks/ instructions may need to be broken down into smaller steps or they may need some assistance with getting started. Think about your child’s own strengths & weaknesses. FUN! We all need to have some fun in life in order to be happy & enjoy life. Think of things your child likes to do and incorporate them into your daily routine. Have 1:1 time together. - Recommend 20- 30mins minimum - e.g. reading a book, drawing/painting together, playing hide and seek or even playing with your child’s favorite toy alongside each other. - This can be child led or you can take it in turns to decide what the activity will be.

Strategies Time Out Use for serious behaviours that can’t be ignored (e.g. hitting). Don’t over- use it or it’ll be less effective & become punitive. Explain to child why they are in time out. Time out should be done somewhere safe with no stimulation (e.g. toys) Should not be longer than 5 minutes ; however if child leaves time out they should go back in and the time starts again. Your child should not be allowed out of time out until they have been calm for at least two minutes. Needs to be immediate. Praise Don’t overuse or it starts to lose it’s impact & can start to sound fake. Aim to praise and encourage your child 5 times for every 1 correction. Be specific – Instead of “good boy” say “ I liked how well you tidied up your toys”. Praise effort (e.g. “I could see you tried so hard to…I am so proud of you. Avoid combining it with a put down (e.g. “I liked how well you tidied your toys, shame you can’t do it all the time”). Catch your child being good. It’s easier to notice “bad” behaviour a lot of the time! Be enthusiastic

Strategies cont’d Rewards It may be star charts or may need something concrete. If using star charts never take one away for “bad” behaviour. Be realistic about rewards– they should be fairly small or you’ll end up bankrupt! Also try not to use monetary rewards as it may become expensive for you. Think about what is rewarding for the child– being allowed to spend 10 minutes spinning may be a good reward for a child with ASD. Needs to be immediate- particularly in the initial stages of change. Your child needs to experience the immediate benefits of doing the desired behaviours. Clear goals Identify just one or two difficult behaviours to work on rather than a whole host of things. What behaviours can you ignore? If it does not put your child or others at risk, is it necessary to respond? Try to redirect your child to do what you would like them to do instead or something that is of interest to them. Clearly define what you are aiming for and what your expectations are. Do not keep moving the goal posts. Having these pinned up in a visual form (e.g. “house rules”) can help a child see what is expected of them.

Strategies cont’d Change your responses Sometimes the way we respond to a behaviour may actually keep it going. e.g. A child has a tantrum when you say “NO” and you eventually give them what they want. The child therefore learns that tantrums are a pretty good way of getting what they want!

Supporting communication Be concrete & visual (e.g. visual timetables). Use ideas around “total communication” e.g. support words with gestures, facial expressions. Support with signing / PECS. Keep instructions simple.

The end Questions? Comments? Discussion?