Coping with Challenging Behaviors
REALIZE …
• It Takes TWO to Tango … or tangle…
Learn to Dance with Your Partner
When Something Is Not Working Well…
What Do We Tend to Do?
Being ‘right’ doesn’t necessarily translate into a good outcome for both OR
either of you
Deciding to change your approach and behavior
WILL REQUIRE you to stay alert
and make choices… it is WORK
It’s the relationship that is MOST critical
NOT the outcome of one encounter
Who Are YOUR
Challenging People?
Who Challenges YOU?
What are the Challenging Behaviors that GET TO YOU?
What Are the Most Common Issues That Come Up???
• Not going to the MD• ‘Losing’ Important Things• Getting Lost • Unsafe task performance• Repeated calls & contacts• Refusing• ‘Bad mouthing’ you to
others • Making up stories• Resisting care• Swearing & cursing• Making 911 calls• Mixing day & night• Shadowing
• Eloping or Wandering• No solid sleep time• Getting ‘into’ things• Threatening caregivers• Undressing• Being rude• Feeling ‘sick’• Striking out at others• Falls & injuries• Infections & pneumonias• Seeing things & people• Not eating or drinking• Contractures & immobility
By managing your own behavior, actions, words &
reactions you can change the outcome of an interaction.
REALLY Ask Yourself…
Is this Behavior a Problem Behavior
OR
is this a “So What” Behavior
An “Annoying” Behavior
Is it REALLY a Problem?Is it a RISKY BEHAVIOR?
• Risk to that person (physical, emotional, physiological risk)?
• Risk to the caregiver?
• Risk to Others?
• Is the RISK REAL and IMMEDIATE?
• If NOT, it is a ‘SO WHAT’ behavior
If it is a ‘SO WHAT’ Behavior…
• Leave it ALONE!
• Figure out how to let go of it …
• Let it go!
If it is RISKY…
• Describe the behavior – OBJECTIVELY– WHO?– WHAT?– WHERE?– WHEN?– WHAT helps… WHAT makes it worse?– Frequency & Intensity?
SIX Pieces to the Puzzle
• Personal history and preferences
• Type & current level of cognitive loss
• Other conditions & sensory losses
• Environmental conditions
• Care partner approach and behaviors
• What happened – full day & all players
Knowing the Person
• History
• Values and beliefs
• Habits and routines
• Personality and stress behaviors
• Work & family history
• Leisure and spiritual history
• Hot buttons & comforts
Level of Cognitive Function
What CAN the person do?
What can the person NOT do?
What CUES are effective? Ineffective?
What are interests based on level?
Consistency of Cognitive Level?
The person’s brain is dying
Normal Brain Alzheimers Brain
Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains
G. Small, UCLA School of Medicine.G. Small, UCLA School of Medicine.
NormalNormalEarly Early Alzheimer’sAlzheimer’s
Late Late Alzheimer’sAlzheimer’s ChildChild
So… what is happening?
• Memory damage – Can’t learn new things– Forgets immediate past– Does time & space travel– Uses old memories like new– May not ID self or others
correctly– CONFABULATES– Follows visual cues– Seeks out the familiar– Can get stuck on an old
emotional memory track
• Language damage– Has very concrete
understanding of words– Misses 1 our of 4 words –
may miss “Don’t…”– Word finding problems– Word salad problems– COVERS– Follows your cues– Gets very vague & repeats– Uses automatic responses– Mis-speaks
So… what is happening?
• Impulse Control Problems– Say whatever they are
thinking– Swear easily– Use sex words or racial slurs
when stressed– Act impulsively– Not think thru consequences– Can’t hold back on thoughts
or actions– Responds quickly & strongly
to perceived threats• Flight, fight, fright
• Performance Problems– Thinks they can do better
than they can– Can sometimes DO
BETTER under pressure – sometimes worse
– Uses old habits– Attempts can be dangerous
or fatal– They will tell you one thing
and then do another…– Families may over or under
‘limit’ activities
How do these losses relate to some risky behaviors?
• Persistent ‘going’– inability to terminate
– not able to anything else
– discomfort
• Eloping - escaping– following cues
– wanting to leave
– going somewhere
• Constant talking or vocalizing– Trying to communicate
– Self-stimulating
• Lack of Initiation– Won’t move or cooperate
• Lost and ‘Looking’– can’t find places– looking for familiar
• Invading space– automatic actions– following interests & habits– no awareness of ‘personal
space’
• Shadowing– looking for help– Comfort
• Resisting care– Self-care– Movement
Level 5 - Routines & RepeatsDiamonds
• Word finding problems• Logic problems• Place & time confusion• Very ‘independent’ or
seeking constant reassurance
• Resents take-over• Self-awareness varies• Fearful about what is wrong• Typically resists outside
helpers
• Becomes anxious and frustrated easily
• Has trouble with new routines and locations
• Tries to maintain control & social behavior
• May try to escape/leave
• Can use signage & cues
• Gets ‘turned around’
• Momentarily ‘disoriented’
• Does regular routines JUST FINE!
Level 4 - Task OrientedEmeralds
• Has trouble sequencing thru tasks & activities
• Often skips steps • Looking for what to do
and where to be• Believes they can do it• ‘Don’t need your help’• Has a mission in mind• Goes back in time• Gets lost in place
• Uses visual information to figure out what to do
• Follows samples & demos• Can’t do an activity if visual
prompt is not there• Specifics and content in
speech can be limited• Gets stuck on ‘stuff’• Needs to be involved• Looks for ‘stuff’ to do
Level 3 - Hunting & GatheringAmbers
• Uses hands to touch, feel, handle, hold
• Explores what is visible and hidden
• Invade other’s space to explore
• Repeats actions over and over
• Sees in pieces not whole• Impulsive or indecisive• Understands few words
• Imitates actions – copies you• Tool use is challenging• Follows others• Investigates the environment• May taste or eat what they
see • Difficulty terminating• Difficulty getting focused on
care tasks• Becomes easily distressed
with unpleasant tasks• Asks ?s mechanically
Level 2 - Stuck on GORubies
• Gross motor only• Poor finger use• Limited visual processing• Very limited
communication skills• Unable to do more
complex motor actions• Imitates those around• Problems with chewing
and swallowing
• Can’t stop or sound asleep
• Copies your mood – facial expressions
• Can’t grade strength• Better with rhythm and
repetitive movements• Loses weight• On the move – wanders
forward – no safety awareness
Level 1 – Reflexes RulePearls
• Bed bound or chair bound• Unable to sit up for any
length of time• Unable to communicate
verbally• Lots of reflexes• Breathing changes• Moments of being
present• Can make eye contact &
some automatic responses
• Swallowing and eating problems
• Muscles shorten and contractures forms
• Pressure areas develop because of no movement & limited intake
• Responds to touch, voice, movement, smells
• Startles easily• Motor agitation indicates
needs
Health & Illness
• Mobility problems?
• Pain?
• Sensory problems?
• Mental health issues?
• Other diagnoses of importance?
Comparison of Fat Pads
Environmental Factors & Changes
• Physical Environment
• People
• Programming
Environmental Aids
• Setting– familiar– friendly– functional– forgiving (safe)
Environmental Aids
• Props– visible & invisible– timely– available– matched to ability– matched to interests
Care Partner
Approach
Knowledge
Skills
Three Reasons to Communicate • Get something DONE
• Have a conversation
• Help with distress
Communication – Getting the person to DO
SomethingForm a relationship FIRST
Then Work on Task Attempt
Connect
• 1st – Visually
• 2nd – Verbally
• 3rd – Physically
• 4th – Emotionally
• 5th – Individually - Spiritually
How you help…
• Sight or Visual cues
• Verbal or Auditory cues
• Touch or Tactile cues
To Connect
Use the Positive Physical Approach
Your Approach
• Use a consistent positive physical approach– pause at edge of public space– approach within visual range– approach slowly– offer your hand & make eye contact– call the person by name – stand to the side to communicate– respect intimate space– wait for a response
Hand-Under-Hand Position
Your interaction…
• Communicate with awareness– look, listen, think!– give your name– make an empathetic observational statement
• “You look busy...” • “It looks like you are tired…”• “It sounds like you are upset…”
– wait for a response
Give information
• Keep it short and simple– “ It’s lunch time”– “Let’s go this way”– “Here’s your socks”
• Use familiar words and phrases
• Use gestures and props to help
Encourage Engagement
• ask a person to try• ask a person to help
you• give simple positive
directions - 1 step at a time
• use props or objects• gesture• demonstrate• guide• distract• redirect
Daily Routines & Client-Centered Programming
• Old habits and routines
• Patterns during the 24 hrs
• A time to rest, work, play…socialize
• Your needs… my time
To Cope with Challenging Behaviors…
• Where will you start???– An idea –
• Care partner education• Care partner skill building
Then…
• Observe & document the risky behavior thoroughly– what is the pattern– when does it happen– where does it happen– who is involved– what is said, done, attempted– what makes it better… worse
Is it really a problem?… A RISK
• If NO - leave it alone
• If YES - its time to problem solve– call the team together– put on the thinking caps
REMEMBERExplore all of the following -
• Personal background information
• Level of cognitive function
• Health information
• Environmental issues
• Caregiver approach & assistance
• Habits, schedules & time of day
Re-look at the problematic challenging behavior…
• What does the person need?
• What is the meaning of the the behavior?
• Do you understand the risky behavior better?
Make a PLAN!
• Who will do what• When will it be done• How will it work• What environmental change is needed• What props are needed - where will they
be
Implement your plan!
• Keep track of progress• Document what is happening• Communicate among the team members
• Rethink - if it isn’t working….
• CELEBRATE - if it is!
How can we help… better?
It all starts with
your approach!
How you help…
• Sight or Visual cues
• Verbal or Auditory cues
• Touch or Tactile cues
What Do They Do?
• Question
• Refuse
• Release – verbal
• Intimidate – physical
• Tension reduction
What Should You Do?
• Be supportive
• Offer choices & be directive
• Set realistic limits
• Act – Take control
• Re-connect
Believe -
People
Are doing
The BEST they can!
What shouldn’t we do???
• Argue
• Make up stuff that is NOT true
• Ignore problem behaviors
• Try a possible solution only once
• Give up
• Let them do whatever they want to
• Force them to do it
So WHAT should we do???
Remember
who
has the healthy brain!