New Hire Test #5: Mental Retardation Behavioral Supports

Communicating Through Behavior
Individuals with mental retardation often have communication difficulties (such as being unable to talk or understand spoken language) that get in the way of expressing their needs and feelings in usual ways. This may lead to expressing those needs through behavior that appears unusual or disturbing. Historically, those individuals whose behavior is difficult to manage have been considered in need of institutionalization until they learn behaviors that “show” that they are “ready” for life in the community. However, we have learned that teaching positive behavior in the individual’s community home and work settings is a better way to help individuals with mental retardation to change their behavior. Additionally, problem behaviors of many institutionalized people disappear once they participate in the community. In order to be successful with behavioral supports, staff must treat individuals with dignity and respect. Support staff must view behavior as a way for individuals to control and direct their own lives. If the desire for personal choice and control is not respected, it may result in an individual adopting negative behaviors to gain some control. For example, the person who is never asked what she wants for breakfast may start to throw her oatmeal across the kitchen every morning. In addition, behavioral interventions should be developed with the whole individual in mind, not just the problem behavior. We must look at the behavior within the framework of the person’s life. People who have few opportunities to participate in meaningful activities they enjoy with people they like are more likely to display negative behaviors out of boredom or unhappiness. For example, the staff’s idea of a community outing is to load up the group home van with all 5 residents and go to McDonald’s every Friday night. Bob resists getting on the van and has begun taking off his seatbelt and hitting whoever is sitting next to him. In this case, helping the person to find and participate in enjoyable activities with people he likes may go a long way toward removing the reason for the negative behavior. It is learned that Bob hates going places in large groups, and he also doesn’t like burgers. A companion is found to take Bob, one-on-one, to some local diners and
cafeterias on Friday evenings. Additionally, people (with or without mental retardation) generally do not behave at their best when they are feeling pain or discomfort. A person who is hungry, thirsty, or tired may act in a negative way to express these feelings. Some problem behaviors result from side effects of medications. Others result from unhappiness, which may be due to missing family or friends, the absence of a favorite staff member, dislike of work, or an argument with a housemate or coworker. Reasons for behavior are as unique as individuals. If we are to support people in successfully changing problem behaviors, we must first do our best to know these individuals and what is happening in their lives.

Functional Assessment of Behavior
When a behavior interferes with an individual’s ability to live or work successfully in the community, the first step in addressing the behavior of concern is to try to figure out the purpose of the behavior. This is done by first defining the problem behavior, in ways that can be seen and measured.
In our example of Bob, staff might be making notes such as:
“At first Bob refused to get on the van for a trip to McDonalds.”
“Once on the van he began hitting his neighbor.”
“At the intersection, Bob took off his seatbelt.”
“Bob ate little of his dinner tonight. Ate most of his salad and pie, but only took one bite of his hamburger.”
Information is then gathered which may tell us why the person is acting in that way. This information is provided through formal data collection tools, such as documentation of the times and frequency of the behavior, and informal tools such as interviews of staff, family, and/or other care providers who support the person. Information such as when a behavior occurs, what is going on around the person at the time, who else is present, and what happens immediately following the behavior can be critical in determining the purpose or function of the behavior. What happens immediately after the behavior, is probably (but not always!) what the individual was wanting. Staff working with Bob may also note that the van stops to deal with Bob’s behavior of hitting and unbuckling, delaying the trip, or that the “consequence” for his behavior is that he doesn’t get to go on the trip the next week (just what he wa nted all along!).

Intervention
Changing the Environment or Routines
Once the function of the behavior is determined, the most important step involves making changes in the individual’s surroundings or routine and starting new supports to eliminate or prevent the need for the behavior. For example:
– If a person is behaving aggressively due to a toothache, assisting the person with getting treatment from a dentist should help to stop the need for the behavior.
– An hour of relaxation after work may help someone do better during the evening hours.
– Individual time with staff may reduce the need to scream for attention.
Sometimes all it takes to help an individual behave in less challenging ways is to change the setting (reduce the noise, limit the number of people, go someplace she likes), change our behaviors (ask rather than demand, talk about the day’s schedule, speak quietly) or change our expectations of him (give him more time to eat, let him choose the day’s fun activity, not require him to participate).
For Bob, the setting was changed (limiting the number of big group van trips in which he’s expected to participate and taking him to restaurants that don’t just feature burgers as their main offering). Also, the staff’s expectations of Bob were changed (he can choose different restaurants and go with a companion instead of “the big group”).
Teaching a New Behavior
While things usually get better by making the above kinds of changes, this might not totally address the behavior of concern. When this is the case, the next step is identifying and teaching a new or “replacement” behavior that would give the person another way to get his need met.
For example, if a person is hitting people as a way of communicating that he wants to stop participating in an activity, an effective replacement behavior might involve teaching the individual to show that he wants to stop by handing a card to support staff.
If this gives the individual the same results, as quickly and consistently as the problem behavior does – that is the demand from staff to participate in the activity is removed – then the individual may learn that he does not need to continue hitting others in order to communicate that message.
In teaching a replacement behavior, it is important that the new behavior works every time for the person.
In the example of the person communicating that he wants a break, handing the card to a staff member must be effective in getting a break, if the person is to learn that this is an efficient replacement behavior.
It is also important for staff to point out positive consequences, which flow naturally from the new behavior and make it more likely that the person will engage in the behavior again.
For example, when a person bathes, she experiences feeling/smelling clean. She
may enjoy this feeling and, thus, be more likely to want to bathe.
In addition to responding consistently to positive behavior, support staff must be ready to respond effectively when problem behaviors occur. If a behavior will not harm the person or others, it is often best to ignore the problem behavior, while continuing to respond consistently to the desired behavior that the individual is learning.
Staff working with the person resisting bathing would ignore her high pitched squeals at bath time and remind her how good she’ll feel and smell after her bath. The behavior plan might also call for staff to offer her choice of bubble bath or scented soap.
When behavior places the individual or others in danger, ensuring safety and minimizing risk become the immediate focus. Staff should not try to teach desired behaviors during a time when dangerous behavior is occurring. It’s best not to worry about what is learned during these times or that the individual might be “getting his way.” It’s more important for everyone to be safe and calm (and to learn from these experiences what the individual really wants so that he can be supported in a way that helps him to be happy with his life). When the individual becomes calm, the focus can again turn to teaching the better way to behave. Much behavioral support is provided through unplanned or social teaching. Individuals with mental retardation, like all people, learn from watching how others act in a given situation. This is why teaching behavior in the community settings where the person lives and works is very effective. The individual must be provided with opportunities to experience different environments – stores, restaurants, banks, ballparks, hair salons – in order to learn to interact with others in those environments. Support staff who go with an individual in community environments must remember that you are a role model not only for the individual to learn how to behave, but also for the people in the community that the individual meets. If you treat the individual respectfully, you will show others how to do so also.
Behavior Support Plans
Individual behavioral support plans are often developed for persons who have particularly challenging behaviors. Once the appropriate interventions are identified through the functional assessment process, a behavior support plan should be developed to teach the individual the desired behavior. A behavior support plan outlines what changes are needed in the environment or the individual’s schedule or routines, how staff should support the individual and respond when the behavior occurs, what new behavior the individual can use to get what he needs and wants, and the methods for teaching the person the new, replacement behavior. Behavior support plans are designed to help staff be consistent, that is to act in the same way, in supporting the individual. In supporting behavioral change, human rights protections are a primary consideration. The Department of Mental Health, Mental Retardation and Substance Abuse Services has established guidelines to protect the rights of individuals served by providers licensed by the Department. Each such provider is required to have a human rights policy, which has been approved and which provides adequate protections for individuals served by the agency. If you work for a DMHMRSAS-licensed provider, you will receive additional training regarding the human rights policy which applies in the agency where you work. Behavior intervention plans must comply with the human rights regulations and policy. In general, restrictions of an individual’s rights, even those done for the purpose of teaching behavior, should be avoided. At the very least, they must be part of a formal behavior support plan.

Your Role – What Can You Do?
1. Be a good role model. It will be difficult for people to look to you to teach them anger management if they see you yell and scream when you get angry.
2. Be a good observer. As a direct service staff member, you will have the most contact with the individual and will generally be the first to notice changes in behavior or behaviors that are interfering with the person’s life in the community.
3. Keep good documentation. Your observations are critical in determining the purpose (or function) of a challenging behavior. Record accurate information regarding patterns of behavior: times, places, surrounding events, what happens after he does it.
4. Follow behavior support plans. In order to support people effectively, the same (consistent) teaching strategies must be used by all staff. In addition, behavior plans must comply with human rights guidelines. By carefully following behavior support plans, you help make sure that the person’s rights are protected and that the new, replacement behavior is successfully taught.
5. Be a good communicator. If individuals are verbal, listen to what they tell you about their choices with words and behavior. If individuals are non-verbal, pay close attention to what they tell you through behavior. By doing this, you will often be able to assist people in exercising choice and control, which will make it less likely that negative behavior will develop.
6. Be supportive and respectful. The individuals with whom you work have the same desire you have to be accepted in the community. Socially unacceptable behaviors may have been learned for a variety of reasons based on the individual’s life history and experiences. When you treat people with respect they are more likely to trust that you are trying to help reach their goals and, thus, you will be a better teacher.
7. Commit to problem-solving. When a person lives in the community, problems may arise due to behaviors that keep the person from fully participating in community life. Put your creativity and energy into helping find solutions that increase the person’s ability to become a valued, participating community member.
8. Assist individuals with improving quality of life. Many negative behaviors are due to boredom and unhappiness. Look at people’s lives to see if they have opportunities to make friends, participate in activities they like, and take on new challenges. Find ways to help each person increase those opportunities. For example, go with a person to join a club that focuses on the individual’s interests.
9. Point out natural reinforcers. Help individuals with whom you work to notice the positive effects of certain behaviors. Walk with a person who has just combed his hair to a mirror and point out how good his hair looks. In time, he may go to the mirror alone and note whether the grooming was successful.