1. Effective Behavior Management Strategies for the Substance-exposed Child Erin Telford, Psy.D. Children’s Research Triangle

2. © Children’s Research Triangle 2006 Agenda Prenatal substance exposure and behavior management Prenatal substance exposure and behavior management What is behavior management? What is behavior management? Behavior management strategies Behavior management strategies Behavior plans Behavior plans

3. © Children’s Research Triangle 2006 Agenda Prenatal substance exposure and behavior management Prenatal substance exposure and behavior management What is behavior management? What is behavior management? Behavior management strategies Behavior management strategies Behavior plans Behavior plans

4. © Children’s Research Triangle 2006 Prenatal Substance Exposure and Behavior Management Children with a history of prenatal substance exposure have difficulties with: Children with a history of prenatal substance exposure have difficulties with: Abstract concepts Abstract concepts Anticipating consequences Anticipating consequences Connecting their behavior Connecting their behavior

5. © Children’s Research Triangle 2006 Prenatal Substance Exposure and Behavior Management Impairments in information processing are common Impairments in information processing are common Sequencing is difficult Sequencing is difficult RESULT: “traditional” discipline often ineffective RESULT: “traditional” discipline often ineffective

6. © Children’s Research Triangle 2006 Research on Behavior Management Little research on effective behavior management Little research on effective behavior management Recommended treatment is often not based on research but child’s clinical picture Recommended treatment is often not based on research but child’s clinical picture Positive behavior programming, consistency, and concrete interventions are effective (Miller, 2005) Positive behavior programming, consistency, and concrete interventions are effective (Miller, 2005)

7. © Children’s Research Triangle 2006 Agenda Prenatal substance exposure and behavior management Prenatal substance exposure and behavior management What is behavior management? What is behavior management? Behavior management strategies Behavior management strategies Behavior plans Behavior plans

8. © Children’s Research Triangle 2006 What is the goal of behavior management? To understand the child’s behavior To understand the child’s behavior To understand contributing factors to the child’s behavior To understand contributing factors to the child’s behavior To increase child’s independence by teaching them skills To increase child’s independence by teaching them skills And, of course, to change negative or problematic behaviors! And, of course, to change negative or problematic behaviors!

9. © Children’s Research Triangle 2006 Reinforcement versus Punishment Behavior Increases Behavior Decreases Stimulus Applied Positive Reinforcement Positive Punishment Stimulus Removed Negative Reinforcement Negative Punishment

10. © Children’s Research Triangle 2006 Does Punishment Work? In one word…yes! In one word…yes! Punishment is extremely effective in getting a quick response or behavioral change Punishment is extremely effective in getting a quick response or behavioral change Behaviors generally end quickly Behaviors generally end quickly

11. © Children’s Research Triangle 2006 Then what’s the problem? Punishment is effective but there are problems… Punishment is effective but there are problems… Generalization Does not generalize well Punishment across environmental contexts Practical problems Community use Individual reactions

12. © Children’s Research Triangle 2006 What can we do? Proactive Strategies Decrease the frequency of behavior Decrease the frequency of behavior Decrease intensity of a behavior Decrease intensity of a behavior Goal: to prevent negative behaviors before they occur Goal: to prevent negative behaviors before they occur Reactive Strategies Immediately stop a potentially dangerous behavior Goal: get control over a behavior quickly

13. © Children’s Research Triangle 2006 Agenda Prenatal substance exposure and behavior management Prenatal substance exposure and behavior management What is behavior management? What is behavior management? Behavior management strategies Behavior management strategies Behavior plans Behavior plans

14. © Children’s Research Triangle 2006 Proactive Strategies Proactive Strategies Environmental Manipulation Planned Environmental Changes Direct Treatment Any Intervention Directly Affecting Child Positive Programming Teaching New Skills

15. © Children’s Research Triangle 2006 Environmental Manipulation Settings Interactions Instructional methods Characteristics of other people Instructional/personal goals Environmental pollutants Number of people

16. © Children’s Research Triangle 2006 Suggested Environmental Strategies Plain walls Plain walls Avoid mobiles/hanging items with young children Avoid mobiles/hanging items with young children Soft lighting Soft lighting Cover part of windows if distraction is an issue Cover part of windows if distraction is an issue Limit open spaces by providing visual or physical boundaries Limit open spaces by providing visual or physical boundaries Label areas with pictures and words Keep areas clean – only have out materials being used

17. © Children’s Research Triangle 2006 Suggested Environmental Strategies Help child organize personal space Help child organize personal space Do not unexpectedly change the work/personal area Do not unexpectedly change the work/personal area Minimize extraneous noises Minimize extraneous noises Picture cues Picture cues

18. © Children’s Research Triangle 2006 Direct Treatment Reinforcement schedules Reinforcement schedules Stimulus control Stimulus control Medication adjustment Medication adjustment Dietary changes Dietary changes

19. © Children’s Research Triangle 2006 Direct Treatment Suggestions Consistency across contexts Consistency across contexts Plan, structure, and organize Plan, structure, and organize Predict Predict Distinguish between willful behavior and neurological deficits Distinguish between willful behavior and neurological deficits

20. © Children’s Research Triangle 2006 Direct Treatment Suggestions Eliminate overwhelming stimulus before it occurs Eliminate overwhelming stimulus before it occurs Learn what child values for reinforcement schedules Learn what child values for reinforcement schedules Make “choice cards” for positive rewards Make “choice cards” for positive rewards

21. © Children’s Research Triangle 2006 Positive Programming ALL behavior has a purpose ALL behavior has a purpose Need to teach news skills for behaviors you want to eliminate Need to teach news skills for behaviors you want to eliminate Teaches: Teaches: 1. General skills 2. Functional skills 3. Coping skills

22. © Children’s Research Triangle 2006 Suggested Positive Programming Strategies Gradual shift from external to internal control Gradual shift from external to internal control Teach strategies for self-regulation Teach strategies for self-regulation Encourage self-monitoring Encourage self-monitoring Model calm, organized behavior Model calm, organized behavior

23. © Children’s Research Triangle 2006 Suggested Positive Programming Strategies Emphasize thinking skills (How did you figure that out?) Emphasize thinking skills (How did you figure that out?) Teach “habits” Teach “habits” Teach relationship skills Teach relationship skills Teach problem solving skills Teach problem solving skills

24. © Children’s Research Triangle 2006 Reactive Strategies A reactive response can reinforce the negative behavior A reactive response can reinforce the negative behavior Reactive strategies can include punishment Reactive strategies can include punishment Reactive strategies are always necessary when designing a good treatment plan Reactive strategies are always necessary when designing a good treatment plan

25. © Children’s Research Triangle 2006 Suggestions for Reactive Strategies Be firm, not punitive Be firm, not punitive Consistently adhere to rules Consistently adhere to rules Wait until child is calm and de-escalated before intervening Wait until child is calm and de-escalated before intervening Avoid debates, just state the rule Avoid debates, just state the rule Avoid punitive consequences such as isolation Avoid punitive consequences such as isolation Use reactive strategies only to get immediate control over a potentially dangerous situation Use reactive strategies only to get immediate control over a potentially dangerous situation

26. © Children’s Research Triangle 2006 Agenda Prenatal substance exposure and behavior management Prenatal substance exposure and behavior management What is behavior management? What is behavior management? Behavior management strategies Behavior management strategies Behavior plans Behavior plans

27. © Children’s Research Triangle 2006 Behavior Management Plans I ndividualized I ndividualized A ssessment-based A ssessment-based C onsistent C onsistent G oal oriented A cross contexts C omprehensive

28. © Children’s Research Triangle 2006 Step 1: Pick behavior Pick specific behavior to work on Pick specific behavior to work on Prioritize: what behavior needs to change? Prioritize: what behavior needs to change? Once a behavior is chosen, define it: Once a behavior is chosen, define it: What does the behavior specifically look like? What does the behavior specifically look like? How long does the behavior last? How long does the behavior last?

29. © Children’s Research Triangle 2006 Prioritize Behaviors

30. © Children’s Research Triangle 2006 Step 2: Track Behavior Want to get a good understanding of what is contributing to the behavior Want to get a good understanding of what is contributing to the behavior Ask: Ask: What occurred IMMEDIATELY before the behavior? What occurred IMMEDIATELY before the behavior? What occurred afterwards? What was the consequence of the behavior? What occurred afterwards? What was the consequence of the behavior? When did it occur? When did it occur? How often does it occur? How often does it occur?

31. © Children’s Research Triangle 2006 Sample Behavior Tracking

32. © Children’s Research Triangle 2006 Step 3: Analyze Behavior Once the behavior is tracked, analysis is easier Once the behavior is tracked, analysis is easier Analysis should take place based on the earlier dimensions: Analysis should take place based on the earlier dimensions: Environmental factors Environmental factors Direct interventions Direct interventions Skill deficits Skill deficits

33. © Children’s Research Triangle 2006 Sample Behavior Analysis

34. © Children’s Research Triangle 2006 Step 4: Create Plan Identify interventions under each area: Identify interventions under each area: 1. What changes can be made in the environment to decrease the behavior? 2. Can any behavior be reinforced to increase it? 3. Does there need to be any changes in medication? Diet? 4. Are there skills that the child can be taught to replace problematic behaviors? 5. What are the minimal reactive strategies? When are they implemented?

35. © Children’s Research Triangle 2006 Case Example 7 year old girl 7 year old girl Frequent tantrums Frequent tantrums Triggers: transitions, frustration, communication problems, limits Triggers: transitions, frustration, communication problems, limits Impulsivity and inattention Impulsivity and inattention Home environment is chaotic with limited space Home environment is chaotic with limited space Traditional behavior management ineffective Traditional behavior management ineffective

36. © Children’s Research Triangle 2006 Case Example Environmental Strategies Difficult to change the child, but can change the environment Difficult to change the child, but can change the environment Create a personal space Create a personal space Minimize extraneous people in the home Minimize extraneous people in the home Decrease noise Decrease noise Sensory integration evaluation Sensory integration evaluation Transition warnings Transition warnings

37. © Children’s Research Triangle 2006 Case Example Direct Treatment Strategies Referral for psychiatric evaluation Reinforcement schedule for positive behaviors “External brain” strategies

38. © Children’s Research Triangle 2006 Case Example Positive Programming Strategies Relaxation techniques for when feeling overwhelmed Relaxation techniques for when feeling overwhelmed Supplemental communication strategies to use when feeling overwhelmed or frustrated Supplemental communication strategies to use when feeling overwhelmed or frustrated May include break or help cards May include break or help cards Simple cues that patient can give others Simple cues that patient can give others

39. © Children’s Research Triangle 2006 Case Example Reactive Strategies “Cool down” time if escalating (in personal area already created) “Cool down” time if escalating (in personal area already created) Removal from the situation if aggressive Removal from the situation if aggressive Holding patient Holding patient

40. © Children’s Research Triangle 2006 Step 5: Review and Revise Children are not static, so their behavior plan should not be static! Children are not static, so their behavior plan should not be static! Have frequent reviews and revise as needed Have frequent reviews and revise as needed

41. © Children’s Research Triangle 2006