It may be possible to lessen a challenging (problem) behaviour by altering the person's circumstances to make it less likely that the behaviour will occur.
Janet Carr (UK)
People with learning disabilities have a particular need of help both with learning skills and with unlearning problem behaviours, and particular methods exist to supply this need. Behavioural management has much in common with teaching and management methods in general but includes some special features. It is applicable to both children and adults, although naturally the context in each case will differ.
It is important to emphasise at the outset that there is no one method that should be prescribed for any one problem. The first essential is to study the individual concerned - his or her likes and dislikes, circumstances, idiosyncratic behaviour patterns, history, family set-up, and so on. Only following that study will a treatment programme, tailored to the characteristics of the individual and to his or her environment, be arrived at.
There are however certain procedures that will normally be considered.
- Changing the Surroundings
- Positive Reinforcement
- Differential Reinforcement of Other Behaviours
- Time Out from Positive Reinforcement
- Functional communication training
- Stimulus Control
- The Least Restrictive Alternative
- Fading programmes
Problem, or challenging, behaviour, is defined as: 'behaviour of such 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 or deny access to and use of ordinary community facilities' (Emerson et al 1988). It is important to note that such behaviours are shown by only a minority of people with intellectual disabilities - 6.1% (Emerson 1995, p.24).
Changing the surroundings
It may be possible to lessen a challenging (problem) behaviour by altering the person's circumstances to make it less likely that the behaviour will occur. For example, a young man who could not tolerate noisy places and caused so much disruption that he was no longer taken out to shops and cafes, was given a headset and a portable cassette player with tapes of music that he liked. When he used these they screened out the other noises and he could then be taken out. (See Donnellan et al 1984). By itself this may not change the behaviour but it can help to allow other methods to be put into place and to take effect.
Many of the methods described here involve the use of positive reinforcement. This is defined as: anything which, when it follows a behaviour, increases the likelihood of that behaviour occurring again. So a preliminary to most programmes is the search for and identification of whatever is likely to have that effect for this individual. No assumptions are made as to what this will be - anything assumed to be a reinforcer 'for most people' will not do unless it is known, or can be shown to be, a reinforcer for this individual. The search for reinforcers should be wide-ranging, taking in sensory stimulation - lights, sounds, music, tastes, smells - preferred activities, favourite foods and drinks. Social reinforcers - attention, approval, praise, hugs - are powerful reinforcers for some people but ineffective for others, and for others still may actually be aversive, so cannot be invariably relied on. Whatever is finally selected, it is crucial that it is of great interest to the person concerned, and can be shown to increase any behaviour that it regularly follows. Used to increase appropriate and to teach new behaviours, it works best when given after every occurrence of the behaviour, at least at first.
In some cases the normal response to a behaviour, that would normally be thought of as unpleasant and leading to a decrease in any behaviour it follows, may have a contrary effect for a person with a learning disability. One example of this is remonstrance, disapproval or anger. A person with a learning disability, if he or she enjoys attention, may relish the attention involved in the scolding; even angry attention may be better than none. If this is the case then the scolding will act as a reinforcer, and will result, not in a lessening but rather in an increase of the behaviour, as the person realises that this is a good way of ensuring that people attend to him or her.
Differential Reinforcement of Other Behaviours
One way of diminishing a challenging behaviour is to build up other behaviours, by deliberately reinforcing them, to compete with the target one. These other behaviours may be those that are incompatible with the problem one, ie, it is impossible for the person to do both behaviours simultaneously. So a girl who frequently poked her eyes with her fingers, damaging her sight, was provided with a piece of apparatus which produced sounds and noises that she loved when she pressed its switches with her fingers. While she pressed the switches and heard the sounds she could not at the same time poke her eyes, and the eye-poking diminished.
Sometimes it is not possible to identify a behaviour that is incompatible with the target behaviour. In this case all other behaviours may be reinforced, apart from the target one. Here it is the absence of the target behaviour that is reinforced: the person receives reinforcement for each period of time (five minutes, ten minutes, half an hour or more, depending on the person and on the behaviour) during which the target behaviour has not occurred. The person learns that he or she has a better time when not displaying the target behaviour, and so will display it less.
Next, two methods used to reduce problem or challenging behaviours by withholding reinforcement.
Behaviours that are followed by a reinforcer are maintained or strengthened. This may happen also, inadvertently, with a challenging behaviour. If the reinforcer for this challenging behaviour can be identified it may be possible to determine that it will never again follow the behaviour. Without reinforcement, the behaviour should eventually die out (extinguish).
There are two caveats. First, the reinforcer must be one that can be controlled. Second, the behaviour must be expected to increase initially (the 'extinction burst').
Regarding the first of these: if, for example, it were thought important to reduce a person's masturbation, extinction would not be a suitable method to choose because the reinforcement cannot be externally controlled; if the person masturbates the reinforcement will inevitably follow. Some other method must be looked for.
Secondly, if a reinforcer, which can be controlled, is prevented from following the behaviour, then initially this can result in an 'extinction burst'. The person finds that the expected reinforcement is not forthcoming, so tries a repeat of the behaviour. If still there is no reinforcement the person may raise the level of the behaviour (worsen it). If the reinforcement is rigorously withheld, no matter how much worse the behaviour becomes, the behaviour should then begin to lessen, slowly at first and then more rapidly.
As the behaviour worsens during the extinction burst it may be that the worker in charge of the programme cannot tolerate the increased level, gives in, and gives the reinforcement. In this case the person learns that, even if the original level of the behaviour will not be reinforced, an exacerbation of it will. From then on it is likely that the behaviour will be worse than it was originally. So it is of the utmost importance that, when the use of extinction is considered, the process is carefully thought through, including whether it could be kept up through an extinction burst. If there is any doubt about this it would be better not even to attempt extinction but to use another method.
2. Time Out from Positive Reinforcement
Often referred to as Time Out, but the full title is important. Time out from positive reinforcement is an option where the problem behaviour usually happens when the person is already in a reinforcing situation - eating favourite food, enjoying music, TV, a social situation. Whenever the behaviour occurs, the reinforcement is temporarily suspended. So if the person very much enjoys a social situation, time out could involve him or her being removed from the situation, perhaps to another room, for a short period (say, five minutes, or even less). But, if the person is not interested in social interaction, removing him or her to another room would not remove the reinforcer and would be pointless, even possibly reinforcing (in allowing the person to escape from a situation he or she dislikes). So time out essentially does not mean the invariable use of a time-out room. On the other hand it has been effective where, for example, the person is fond of music, which is playing, or of TV, and on the occurrence of the behaviour the music or TV is briefly turned off.
Functional communication training
Sometimes a challenging behaviour appears to function in people with a learning disability as a way of 'asking' for something. It may be a way of asking for attention, or for a tangible item, or for something to be stopped - a task perhaps, or an aversive situation. In such cases an effective treatment may be to teach the person to use a word or sign to ask appropriately for what they want. So if children are misbehaving in order to get the teacher's attention, teaching them to say or sign 'Come here please' can result in a reduction of the misbehaviour. Similarly if they were misbehaving in order to escape from a too-difficult task teaching 'Help please' can also bring about a lessening of the misbehaviour.
Certain stimuli lead to certain kinds of behaviour - rain prompts us to put on a mackintosh, a red traffic light to stop the car. Without these stimuli, these behaviours might not occur. Similarly it is possible for a stimulus to become associated with a behaviour that is permitted - reinforced - while the absence of the stimulus indicates that the behaviour will not be reinforced. These conditions can be put to use to help to manage difficult behaviours.
A 13 year old boy was causing major problems in school, among them the relentless questioning of staff. Although this sounds a trivial problem, the tensions it produced led on to other difficulties including physical aggression. The boy was given a sticker to wear on his shirt, and was told that when it was on his shirt his questions would be answered. When it was not on his shirt his questions would not be answered; he should wait until the sticker was back on his shirt. At first the sticker was removed very briefly - for 15 seconds, four times in every hour. His questioning dropped off in frequency very rapidly, within three weeks, even when he was wearing the sticker, and the other associated problems declined too.
Stimulus control can be a useful method in some situations. However since, like extinction, it allows for some occurrence of the behaviour, it is not suitable for tackling behaviours that are dangerous either to the person or to others.
Deliberately programming reinforcement
Some of the methods described above involve the withholding or removal of reinforcement. It is then important to ensure that the person gets reinforcement at other times - our aim is to improve, not impoverish, the person's life. So for example, if the reinforcer were attention, which was withheld when the behaviour occurs, the person should receive plenty of attention at other times: not necessarily for any markedly virtuous but simply for acceptable behaviour. This precaution will also make it less likely that other problem behaviours will emerge to take the place of the original one.
The Least Restrictive Alternative
In work with people with learning disabilities we have an ethical obligation to cause them as little distress as possible. Therefore in tackling a challenging behaviour we should at the outset select a method which, while having at least some prospect of being effective, is the least aversive option available (changing the surroundings, differential reinforcement of other behaviours, etc). Only if this is shown convincingly to fail will other, more stringent, methods, be tried.
When a programme has been put into practice and has been effective, the question arises as to how to end it. This applies particularly to methods that involve giving reinforcement ( differential reinforcement of other behaviours, stimulus control). As a rule, the principle is that it should not be stopped abruptly but gradually tailed off. If the reinforcement is suddenly stopped the likelihood is that the behaviour, which had improved, would worsen. So instead the reinforcement can be given at gradually lengthening intervals; for gradually increasing standards of behaviour; or where appropriate, the reinforcement may be transferred to a new target behaviour. Another strategy is to give the reinforcement at irregular intervals - some short, some longer - so that the person cannot predict exactly when it will arrive. This can make it less problematic for the person when the intervals become generally longer, until eventually the reinforcement, for this behaviour, comes to an end.
If the programme has been devised with an appropriate goal - that of improving the person's life - then when it succeeds the person should experience the improvement, finding new sources of pleasure and enjoyment. This too should help to make deliberate reinforcement less necessary.
Carr, E.G., Levin,L., McConachie, G., Carlson, J.I., Kemp, D.C. and Smith, C.E. Communication-Based Intervention for Problem Behavior. A user's guide for producing positive change. Paul H. Brookes Publishing. Baltimore.
Carr, J. (1980, 1995) Helping your handicapped child: a step-by-step guide to everyday problems. Penguin. Harmondsworth. Out of print but should be obtainable through libraries.
Carr, J. & Collins, S. (1992) Working towards independence: a practical guide to teaching people with learning difficulties. London. Jessica Kingsley Publishers.
Donnellan, A., Mirenda, P.L., Mesaros, R.A. & Fassbender, L.L. (1984). Analysing the communicative functions of aberrant behavior. Journal of the Association for Persons with Severe Handicaps 9 (3), 201-212.
Durand, V.M. (1990). Severe Behavior Problems: a Functional Communication Training Approach. Guildford Press. New York
Emerson, E. (1995). Challenging behaviour: analysis and intervention with people with learning difficulties. Cambridge: Cambridge University Press.
Emerson, E., Cummings, R., Barrett, S., Hughes, H, McCool, C. & Toogood, A. (1988). Challenging behaviour and community services: 2. Who are the people who challenge services? Mental Handicap, 16, 16-19.
La Vigna, G.W. & Donnellan, A.M. (1986). Alternatives to Punishment: Solving Behavior Problems with Non-aversive Stragies. New York. Irvington Publishers.
|There is a commentary on this article by Gary Butler, a Training Adviser at St. George's, University of London.|