Behavioral Antecedent Identification & Management

1. Behavioral Antecedent Identification & Management Minnesota Brain Injury Alliance Conference for Professionals April 11, 2013

2. Learning Objectives • Define antecedent, behavior and consequence. • Identify 3 benefits of utilizing behavior tracking forms. • Identify possible patterns that emerge when using a behavior tracking form. • Identify benefits of team communication and resources when addressing behaviors. • Increase knowledge of practical applications and tools available.

3. Behavior Basics • A, B, C’s • Antecedents • Behaviors • Consequences

4. Behavior Basics-A • Antecedents • What occurs immediately before the behavior? • What is occurring in the environment?

5. Behavior Basics-B • Behaviors • What is the behavior we are looking at/want to change? • Be specific. • Be concrete. • Measurable goal.

6. Behavior Basics-C • Consequences • What occurs in the environment immediately after the behavior? • What occurs for the person immediately after the behavior?

7. Documentation/Behavior Tracking

8. Things to consider when tracking behaviors • Be clear and consistent in defining the behavior. • Keep it simple. • Make sure you’re all on the same page (why you’re tracking). • Be clear about tracking time (duration). • Consider the environment (who is there, not there, physical environment). • Be aware of triggers.

9. Team Communication • After defining the behavior, continue the conversation regarding consistency in identifying, reporting and responding to behaviors across environments. • It’s important to remain open to feedback regarding behaviors-sometimes behaviors occur and we become desensitized to them. • Be aware of all team members and their roles, include all team members in communication.

10. What we can learn from tracking behaviors • Patterns • Time of day • Day of week • Relationships to environments/people • Consistent or inconsistent? • How often behaviors occur • How severe behaviors are All lead to identification of antecedents.

11. Role of the Caregiver • Body language • Tone of voice • Patience • Attention to client/cares • Caregiver’s environment/personal stressors • Existing rapport/relationship with client/team • History with similar behaviors • Awareness of client’s history

12. Responsibilities of Caregivers • Know your client • Follow protocols/be consistent. Remain consistent and thorough in observation, reporting and responding to behaviors. • Be clear and concise • Have reasonable expectations • Be aware of the environment (s) • Timing/routines • Communication • Teaming

13. Case Study 1 • Client A sustained his brain injury as a result of a motorcycle accident. He has lived in a group home for 8 years and has challenges such as poor memory, sensory challenges, and impulsivity. Group home staff are accustomed to Client A’s behaviors and there appears to be expectation difference in his house vs. community programming. • Client A participates in a work program two days a week, participated in occupational therapy for a sensory evaluation, and participates in outings with group home staff and residence. • Due to behaviors around sensory issues, a program has been put in place by an Occupational therapist to be used 3 to 4 times a day for 10 min. There has been limited progress with decreasing behaviors during the work program (however this may be due to work not being able to administer the program), and minimal progress in the home environment, despite the sensory program laid out by the OT being done daily as reported and documented by residential staff.

14. Case Study 1

15. Things to consider/strategies • Clients attention span and anxiety level. • Environmental stimuli. • Staff tasks and responsibilities, time of day, available time. • Calming strategies, sensory application. • Sleeping patterns, how the day went, energy. • Fidgets, Disco-Sit (sensory tool), noise canceling head phones, DS player.

16. Follow up/recommendations • Staff awareness of proper sensory protocol and therapy recommendations. • Keep tasks to time of day (less busy), specific time given to the client. • Create a calm and quiet environment, away from clients and electronics. • Keep a consistent log of how sensory diet affects client either positively or negatively and time of day. • Be prepared with items that are beneficial for decreasing anxiety and increasing spatial comfort in all environments.

17. Case study 2 • Client B sustained her brain injury as a result of an illness. She struggles with a variety of behaviors, including low frustration tolerance, impulsivity and has verbal and physical outbursts. • Despite these struggles, she participates actively in her community and while doing that, utilizes transportation services, including Metro Mobility and MNET providers. • Over time, team members have noted behavioral challenges occurring when there were difficulties with transportation.

18. Case Study 2

19. Things to Consider/Strategies • Unpredictable nature of transportation. • Other external factors (weather, traffic, consistency of ride arrangements). • Time of day/day of week for appointment. • What happened prior to waiting for the ride. • Environmental stimuli. • History with transportation. • Client’s variable frustration tolerance.

20. Follow up/recommendations • Increase communication regarding transportation arrangements. • Create and use transportation log for staff and client. • Involve the client in making or checking on transportation to increase responsibility. • Be prepared for the worst case scenario. • Look at planning the rest of the day-avoid overbooking. • Provide supports to build skills in the moment, decrease supports as skills are in place.

21. Sample Transportation Log

22. Case study 3 • Client C is diagnosed with a severe traumatic brain injury and is a diabetic that is having issue with dangerously high blood sugars. Client has difficulty making good food choices both in quantity and types of food she should be eating to maintain a healthy blood sugar range. Client also struggles with impulsivity and food is one of her triggers. • Client C told caregiver she wanted to go out to eat over the weekend. Over the weekend client went to a restaurant with caregiver. Client chose to go to a Chinese buffet for dinner. Caregiver reminded client about her blood sugar levels and asked him how she could make better choices about what she eats at the restaurant. Client went through the buffet line five times and drank 7 large glasses of Mt. Dew. Client’s blood sugar before bed was 520. Care giver reported that she tried to limit the amount of food client was eating but client choose to continue to eat and drink sugary pop.

23. Case study 3

24. Things to consider/strategies • Redirection and distraction. • Review expectation frequently. • Impulsivity when ordering. • Emotional regulation and motivation. • Time of day and when meals occur.

25. Follow up/recommendations • Prevent boredom by offering and planning other activities. • Offer other dining out options. • Review diabetic protocol prior to dining out. • Park far away so client can walk to and from restaurant. • Plan to “run errands” after eating.

26. Additional resources/tools • Existing documentation-behavior plans, discharge summaries, IEP’s, etc. for additional information. • Referrals: sensory integration, neuropsychological testing, pool therapy, recreational programming, yoga, support groups. • Fidgets, Theraball, weighted vests. • Brain injury and behavior specific websites/

27. Questions/Answers

28. Contact information for presenters • Jodi Greenstein, MSW, LICSW, CBIS • jodi.greenstein@couragecenter.org • Sara Nuahn, MSW, LICSW, CBIS • sara.nuahn@couragecenter.org • Patty Schaefer, CBIS • patricia.schaefer@couragecenter.org

29. Thank you