Oh behave!

After discussing, albeit briefly, the experiences of a parent being supported during a difficult time with their daughter, I was reminded, yet again, of how little is properly understood by some professionals about behavioural management, or how poorly communicated their thoughts are to parents.

The starting point of any decision about how to intervene in an escalation or other change in someone’s behaviour, needs to be a holistic overview of that person and their needs.( I apologise now for the use of holistic, but the only good alternative is “global” and I’m not sure that’s any better.)
When I first started training as an LD Nurse, I was told clearly that any behavioural change should prompt you first to look at someone’s physical health. Although a simplistic idea, it is often true that some kind of illness or pain will cause an individual, especially those with communication difficulties, to behave in severe and seemingly irrational ways. For example a young man with cerebral palsy I knew would self-injure due to tooth pain, by punching his chin.

But just looking at physical health is naturally limited. There is a world of other internal and external influences on someone’s behaviour. Resolving this obviously requires a great deal of detective work. You may get lucky, you may not, but there is no short cut, and a thorough global (actually, not so bad) assessment is the only and best way to go. Which means talking to everyone; parents, other professionals, friends, relatives: everyone, and do I need to actually say the person themselves? If they cannot talk, then will still share; spend time with them, any amount is better than none at all.

A common misunderstanding about behavioural management is that it’s somehow about control; control of the person or control of the behaviour. It really, really, really isn’t. Behavioural management is, at its purest, a process of teaching and learning. Fundamentally the individual learning how to more positively behave through their carers’ teaching, but also by carers learning about the person and themselves through the results of the same process. See it as control and you’ll be setting up both the person and their carer to fail.

Another common misunderstanding is to focus only on the behaviour, or indeed how others around the person behave at the time or immediately after. Of course, how the world responds to someone’s behaviour has a massive influence on whether or not they’ll repeat it or stop it, but it is both limiting and overly basic to expect that by merely responding in a textbook, psychological way, the behaviour will stop or decrease.

It’s behavioural basics, but there are 3 aspects to any behaviour; what happens before, what happens during and what happens after. Often just changing what happens during or after can positively affect behaviour, but not always, and rarely completely and ‘forever’.

This is for two hugely important reasons: Firstly, because behaviour is not simply a calm, rational response to a certain situation or stimulus, it is often an emotional out-pouring; an explosion of frustration and distress – as such it is unlikely that ‘teaching’ or ‘learning’ can take place. Secondly, because behaviour never happens without a reason; without addressing that reason, the cause, the behaviour is prone to reoccur

Whatever the cause; immediate events, a lack of effective communication skills, a lifestyle change, hormonal change, ill-health, mental health needs, raised anxiety, undiagnosed conditions e.g. epilepsy etc., just focusing on the consequences will inevitably result in the individual and their carers ‘failing’.
Effective management of behaviour, therefore, needs to be broader than a mere functional analysis of the immediate antecedents, the behaviour and the immediate consequences. It must comprise a full assessment of any and all possible causes, including:

  • physical and mental health needs
  • a lack of skills that would help the person understand the world, be more independent or express themselves,
  • changes, however small, however recent or old, that have occurred in the person’s life or to those around them

Once a possible cause has been uncovered and understood, choosing how to address both it and the resultant behaviour should never just be a case of picking one of a few ‘favourite techniques’, e.g. teaching PECS and using Extinction. Just as every person is unique, so is every family, every lifestyle and every behaviour.

Be clear, both in what technique you choose and how you explain it, that it will take time; the best and most long-lasting approaches always do. Whether it is in teaching new communication skills to help an Autistic boy express his anger safely, sourcing technology to help a physically disabled girl make choices, or restructuring evening routines to help develop a sleep pattern, learning takes time and the kind of learning that makes lifelong changes to behaviour, takes even longer.

Similarly identifying physical and mental health conditions that may be affecting behaviour will take time; hunches often work, especially based on experience and knowledge, but sometimes it will be (all clichés aside) the last thing to be checked.

Finally, fellow professionals, lets avoid the following:

  • giving behavioural advice when you don’t know why the behaviour is happening
  • avoiding the long route because you want to help parents immediately, if it was fixable quickly it probably would have been already!
  • giving behavioural advice when you’re neither qualified or experienced enough to do so; get in someone who is – it’s better to admit ignorance than reveal it through incompetence
  • viewing behaviour as a result of someone’s failings; either the person or their carers
  • giving behavioural advice such as “ignore it”, “praise them more”, “set firmer boundaries”; all might be partially or completely true, but none give objective guidance on how to actual achieve change
  • addressing the consequences without addressing the causes; more often than not, the behaviour will re-occur, or another behaviour will replace it, either way, you will have achieved little
  • don’t expect someone, professional or parent to fundamentally change the way they care/parent; it’s an unfair expectation, instead mould approaches around those carrying them out

I claim no status as an expert. I’ve made all those errors and more; I too have my favourite approaches, “intermittent reinforcement of an incompatible behaviour” being one, but I like to think I’ve learn enough to know how to do it right, how to share my thoughts effectively and how to see the big picture. It is frustrating that people offer crap or incomplete advice and I can’t promise that all problems are solvable, though I always approach all with optimism.However, the solution will only be achieved if the process is carried out thoroughly and correctly, if the professionals involved are skilled and experienced and if they give time, imagination and effort.

NB: This blog was going to be much more concise and reader-friendly. The fact that it isn’t, is due to the subject matter being so huge, indeed, there’s plenty of complete books about it and I could probably write another if not for my poor writing skills and lethargy.

Advertisements

About this entry