For Families and Carers : Supporting behaviour positively

What do we mean by behaviour? Behaviour refers to everything
that human beings (and animals) DO.


We all react to situations and communicate through our behaviour.
For people who have difficulties with other forms of communication, behaviour – things that they do – can be the most effective form of communication.

To call something behaviour you need to be able to see it, count it and describe it.
So, a behaviour (running out of the building) is different from an emotion (feeling scared) and also different from a thought/motivation (“get me out of here!”).

Behaviour can be positive, helpful and useful to the person.
We sometimes call this adaptive behaviour and it can include skills like asking for help, waiting in a queue, getting on with work, doing chores, going on the trampoline to work off energy, listening to music to calm down…….and many other things.

However, behaviour can be problematic to the individual or to other people around them.
This is sometimes called maladaptive or challenging behaviour.
So-called challenging behaviours are often more extreme versions of quite ordinary behaviours.

These behaviours may occur for the first time by chance or by imitating others. The person may continue the behaviour because it is reinforced, or useful to them. We call this learned behaviour.

The following factors influence whether behaviour is seen as acceptable/appropriate, or not:

  • The strength of the behaviour (a heavy shove, rather than a gentle nudge; a tantrum that lasts an hour rather than a minute)
  • The situation in which it occurs (jumping up and down and shouting out in a cinema rather than at a football match)
  • The consequences of that behaviour (banging a toy on the window as opposed to rearranging the sofa cushions)
  • The degree of tolerance of other people – (a baby yanks your hair as opposed to your 15-year-old daughter)

The following diagram (which you can download as a pdf if you wish) shows the many factors that influence our behaviour and that of the people we care for.

You will see that some of these are fixed – age, gender (usually), life experiences for example – but that others can be changed – expectations, physical environment, others’ behaviour and reactions, triggers and results of behaviour.

These factors are the ones we need to use in managing, changing and supporting behaviour positively.

Behaviour support planning


The diagram below outlines the different stages of behaviour support planning.

Click on the green boxes to go to guidance on that section of the process.

Green box - Deciding where to start
 Green box - Understanding behaviour - complete ABC record
     
 Green box - Working out what the behaviour means - functional analysis
 Green box - choosing possible strategies and creating an individual behaviour support plan
     

Where to start


First be clear about the behaviour, or behaviours that you are concerned about.
If there is more than one, you may need to prioritise and decide which to tackle first.

Where ever possible use ‘doing’ words – hitting, kicking, spitting, sitting down in the middle of the pavement, and so on – rather than thinking in terms of being ‘aggressive’, naughtiness or “having a meltdown”.

Secondly ask the question – does this behaviour need to change?
Behaviour may be challenging because it:

  • makes you feel unable to manage the situation
  • is contrary to social norms
  • interferes with everyday activities
  • causes stress to others
  • happens a lot
  • seems to last a long time
  • happens when it is hard to deal with – in public or at difficult times
  • is risky and puts others in danger

You can use the following questions to help you decide/answer this question:

  • Does it restrict his or her access to important experiences?
  • How much stress does it cause and for whom?
  • How frequent is it, how intense and how long does it last?
  • Is it typical behaviour for the person’s developmental age/stage of development?

Completing an ABC record is the next step.

You can download a blank ABC record chart here.

AAntecedents

Antecedents are things that proceed the behaviour/happen before the behaviour or are contributory factors.
They can be divided into SETTINGS and TRIGGERS.

SETTINGS
These are things like the environment …time/place/number of people around but can also be things that affect the person like being tired or hungry.

TRIGGERS
These are more immediate, temporary antecedents…the things that seem to spark off the behaviour, or happen just before. These could be:

  • noises
  • the behaviour of another child or adult
  • being asked to do something
  • an activity coming to an end

B – Accurate description of the Behaviour

  • What did you see?
  • How many times?
  • How long for?

CConsequences/results: what happens next?

When we think about the consequences of behaviour, we are trying to work out what happens as a result of the behaviour. What happens directly after or what happens because the behaviour occurred.

  • Does the person get attention? Are they given something they might like? Are they given more space to themselves?
  • Does the behaviour stop something from happening? Is there a specific task, activity or demand that is avoided?
  • How do other people react or respond to the behaviour?

You can download some example ABC records here.

Working out what the behaviour means


Before planning what to do about a behaviour you want to change, Positive Behavioural Support suggests that you need to spend a bit of time thinking and working out what function or purpose this behaviour is serving for the person.

The ABC records should help you to do this and will be useful in answering some of the questions below.

This will help you to work out the “communicative function” of the behaviour…in other words what is the person trying to say or what need do they want to be met?

It is important to remember also, that the reason a behaviour started in the first place may not be the reason it continues.

This step in behaviour support is sometimes missed out as people are anxious to get on with management strategies. That risks trying out strategies, on a trial and error basis, that are not appropriate so will not work, leading to frustration and disappointment.

That is not to say that there are not some general “good practice” guidelines/hints and tips for managing behaviour in people with Downs’s syndrome.

A Functional Analysis will be needed where behaviour is more complex, entrenched or difficult to understand what is causing it and keeping it going.

Working out the function of a behaviour

Basic functions of behaviours that challenge include:

A bit more about functions of behaviour

The same behaviour can serve different functions for different people or different functions for the same person at different times.

Pamela Lewis gives the following example:

“One child (or adult) might scream because she likes the sound. Another child might scream because she likes the attention that results from screaming. Another child might scream to express frustration at what is being asked of her, with no interest in the resulting sound or attention. A child might scream for all those reasons at different times.” Pamela Lewis, Achieving Best Behavior for Children with Developmental Disabilities: A Step-by-Step Workbook for Parents and Carers, Jessica Kingsley, 2005.

Some more common functions of behaviour are listed below – please bear in mind that these can overlap:

  • Discomfort – physiological or environmental (hunger, pain, temperature etc.)
  • Developmental levels (expectations are either too high or too low)
  • Seeking rewards – in general this is often involved
  • Escape/avoidance of a task or a demand
  • Seeking sensory stimulation e.g. likes the sight of spinning objects, or the feel of water
  • Avoiding sensory stimulation e.g. dislikes certain sounds, or the feel of tags on shirts
  • Difficulty with organisation needed to initiate an appropriate activity
  • Attention seeking/wanting to interact and not knowing how to do this appropriately
  • Getting a reaction/making something happen (function is control, rather than social attention)
  • Expressing frustration/anger
  • Expressing fear
  • Difficulty waiting
  • Expressing “Wait! Let me finish!”
  • Expressing “No!”
  • Other communication e.g. “I need some help”, “I don’t understand”, “Go away”

Making sense of behaviour

Analysing the ABC charts or other records, and thinking about the possible functions described above should help you to get an idea of what is going on, why the behaviour is happening, what it means to the person with Down’s syndrome.

Often it is good to discuss this with others in the family, or school, other carers etc.

It is also helpful to think about exceptions; situations and circumstances where the behaviour does not occur, or where the person manages to respond to triggers in a different way.

This questionnaire can be used to help decide on communicative function (pdf).

Proactive and Reactive Strategies


Proactive strategies are intended to make sure the person has got what they need and want on a day to day basis and also includes ways to teach the person appropriate communication and life skills.

Reactive strategies are designed to keep the person and those around them safe from harm. They provide a way to react quickly in a situation where the person is distressed or anxious and more likely to display challenging behaviour.

A good behaviour support plan has more proactive strategies than reactive ones.

Antecedent (preventative) strategies

Antecedent strategies are those which prevent the behaviour from happening.

Over time this leads to new behaviours being practised and old (challenging) behaviours disappearing as they are not being practised.

Some prevention strategies to consider include:

  • Keeping the person engaged with positive activities.
  • Avoiding some situations for now e.g. busy supermarkets, crowded tube stations.
  • Removal or avoidance of triggers e.g. make changes to the environment or manage sensory input e.g. ear defenders, use of quiet areas.
  • Reducing the demands placed on the person.
  • Giving more structure to the day.
  • Giving clearer expectations/rules using visual supports, planners and timetables, ‘now’ and ‘next’, visual guides and social stories.
  • Giving advanced warnings and preparation.
  • Desensitisation – gradual supported exposure to triggers.
  • Give the person more praise, attention and rewards as a matter of course.
  • Pre-specified reinforcer – reminding person of rewards to follow e.g. a fun activity.
  • Preferred item as distractor – a task or item that takes the focus away from the trigger e.g. responsible for carrying something into class after playtime.
  • Offer choice.
  • Embed the action that the person is reacting to or finding difficult in a sequence of things you know they like.
  • Indirect requests…offer of collaboration e.g. “Let’s go and…”, “You first, then me…”

Replacement (new skills and behaviour) strategies

To do this, we need to ask, “What do we want the person to do instead?”

The focus of this step is on helping the person learn new skills and encouraging more acceptable or constructive behaviours.

It is important to find things for them to do which are adaptive, but which also meet the same needs as the challenging behaviour (i.e. they obtain the same result).

Here is a suggested list of skills that you might consider teaching the person to help them to cope with challenging situations:

  • Functional communication training – help/escape/finish/bored/attention…
  • Skills in making and communicating meaningful choices.
  • Social skills – situations relating to others, doing things together, friendships/relationships. The right thing to do with the right person in the right place.
  • Sensory activities – support to find alternative ways of gaining the sensory input needed.
  • Play skills – new ways to play, have fun and keep busy.
  • Emotional literacy – teach understanding and communicating feelings.
  • Coping and emotional regulation skills – worries/anxiety, anger/frustration e.g. use of safe place.

When helping people to develop and learn new skills to replace unwanted behaviours it is important to think about their developmental age and stage of development, level of understanding and communication skills.

Bear in mind how people with Down’s syndrome learn best so provide lots of visual supports, modelling, developing personal books and films with lots of practice and repetition.

Consequence (changing the results) strategies

Using rewards and reinforcement

Rewards are one of the most powerful tools we have for changing behaviour.

At some level, each of us is aimed at getting more rewards/satisfaction. How long would you carry on going to work if you stopped getting paid at the end of the month? If you smile and say hi to your new neighbour and they turn away and ignore you, are you likely to do it again?

A reward is anything that tends to increase the behaviour that precedes it. We know that challenging behaviours continue to happen because they are being rewarded in some way (even if we can’t see it immediately). In Positive Behaviour Support, we sometimes like to call rewards reinforcement.

There are two types of reinforcement – positive and negative reinforcement. Both will increase the likelihood of behaviour that they follow, occurring again in the future. So, both act as rewards for the person, making that behaviour more likely to occur again in the future.

Positive reinforcement is when something desirable (e.g. food, drink, attention, activity, star, smiley face etc.) arrives following the behaviour.

Negative reinforcement is when something undesirable (pain, demands, noise, unwanted social attention) is removed following the behaviour.

For example:

Child is screaming and banging her head on the table. Dad picks her up and starts tickling her. She stops crying and starts to giggle.

The child’s behaviour is rewarded by a cuddle and tickle from dad. (Positive reinforcement)

Dads behaviour is rewarded as his daughter stops crying and hurting herself. (Negative reinforcement).

In order to be effective, rewards must be:

  • Meaningful and desirable for the particular person, or motivating
  • Given frequently, especially at first
  • Given at the right time, immediately after the desired positive behaviour is best
  • Given with enthusiasm
  • Changed if cease to be motivating or person’s preferences change.

Choosing rewards

Selection of reinforcers (rewards):

  • Need to be individualised, meaningful to the person;
  • Need to be more powerful than those maintaining the challenging behaviour;
  • Need to be readily available;
  • Need to be affordable – stars, stickers can be exchanged for treats like a trip for McDonalds or a toy, or a trip to a play park;
  • Often, praise and attention are enough but sometimes people need something more tangible; and
  • May need to be changed sometimes, as can lose power over time.

Occasionally it can be hard to work out what exactly motivates a person, especially if they have very limited communication skills.

The following checklist includes suggestions of all sorts of possible rewards to use. It is a good idea to develop a “Reward Menu” of things that can be used to motivate a particular person with Down’s syndrome.

Click here or on the image to download the checklist.
Example simple visual guide
   Example simple reward chart

Changing the Consequences (results) of undesirable behaviour

As well as noticing, and providing rewards/reinforcement for positive behaviours, it may be important to change what happens after an undesirable behaviour.

It is important that undesirable behaviours are not rewarded or reinforced by our reaction, or the person getting the thing they want, or getting out of, or away from a task or situation they don’t like. The ABC records should help to show if this is happening.

  • Removing or stopping a reinforcing consequence from a behaviour is called extinction. If the behaviour stops “working” for the person it will eventually extinguish, or fizzle out.
  • Planned ignoring is a form of extinction, very powerful if we think the behaviour is maintained by the reaction it gets, though sometimes easier said than done!
  • “Time Out” which may be directing the person to sit in a particular place (chair or step) with no interaction for a few minutes, or turning the TV off for a few minutes, is also a form of extinction. It is saying to the person “you are not going to get anything good out of this behaviour”.
    NB: It is different from, for example, sending someone to their room, or outside to calm down. Bedrooms and gardens usually have toys/things to do in them. This might be a good strategy for redirection (see below) but it is NOT Time Out.
  • If a behaviour is not getting the result it used to, a person may often try harder, at first, to get the result so you may see an increase in behaviour to start with. This is called an “extinction burst” and will not be disheartening if you are prepared for it. So sometimes you can expect the behaviour to get worse before it gets better – clearly this would not be appropriate where there are safety issues e.g. hurting self, or running off.

Putting Consequence Strategies together
INTERRUPT -IGNORE- REDIRECT- REWARD

Interrupt – Ignore – Redirect- Reward

The first rule is that no harm should come to anyone. Therefore, aggression, self-injury or severe destructive behaviours should not be allowed to continue.

Interruption means

  • Not reprimanding the person
  • No particular attention should be given to the person about the problem behaviour
  • Redirect at the earliest opportunity with the goal of providing reward for any approximation to positive/desired behaviour.
  • Interrupt in an ‘ignoring’ manner as much as possible
  • Do the minimum to manage the behaviour to stop injury to anyone. This can be achieved by raising forearms to block/protect yourself or quietly ‘shadowing’ the hands of the person who self-injures.

How to Ignore

  • No consequences are given which relate directly to the behaviour
  • Activities continue, do not stop what you are doing
  • Do not ignore the person only the behaviour
  • Continue as if behaviour has not taken place

Its purpose is to defuse undesirable behaviour and take away its power

How to Redirect

  • Redirection is a prompt or cue to engage in a behaviour so that a reward can be given
  • To communicate alternative means of interaction
  • Your message is “DO THIS INSTEAD”
  • Purpose is to encourage participation
  • It communicates that behaviour, which previously stopped interactions or gained inappropriate attention, is no longer effective
  • It is often better to use physical and gestural prompts with brief verbal cues
  • Use non-verbal prompts such as pointing, touching materials, touching the person hand/arms to focus the person’s attention to the task
  • Accept any participation by the person and immediately reward this with a positive response (warm verbal comment, physical contact, smiles) and continue assistance towards desired behaviour or task

Learning strengths and challenges associated
with Down’s syndrome

People with Down’s syndrome tend to learn more easily through ‘visual –spatial’ information and experiences. They learn particularly well from seeing and doing things and benefit from having language information translated into visual information (e.g. pictures, drawings, photos, visual-spatial grids/sequences, books, films, watching others/a model to copy etc.).

People with Down’s syndrome have learning challenges associated with developmental delay (learning disability) and language. For people to change their behaviour, they need to know and remember what they are supposed to do and why, and be motivated to behave in new or different ways. They need to be able to override behaviour they learned in the past. Having a learning disability and language delay makes this even more difficult to do.

We all benefit from support to change behaviour habits. Support can come from the people and the environment around us in many ways. With support, people can learn new behaviours to meet their needs. Over time, these behaviours become their new ‘history’ of learned behaviour.

Using visual supports, being prepared and practising new behaviours in real situations helps people with Down’s syndrome to learn. Knowing about an individual’s learning strengths and motivations, and following the steps in this ‘Supporting Behaviour’ resource will help family members, carers and practitioners understand possible underlying reasons for behaviour and lead to successful outcomes.

Do’s and Don’ts of behaviour management – General top tips

  • Stay Calm
  • Notice positive behaviour
  • Ignore negative behaviour as much as possible
  • Use distraction/redirection
  • Be consistent
  • Account for developmental rather than chronological age
  • Separate immature behaviour from deliberate challenging behaviour
  • If you are getting stressed or frustrated take a break/change person dealing with the behaviour (if possible)
  • Smile and be enthusiastic
  • Give positive praise “Well done”,  “Nice One”,  “Good work”
  • Make eye contact
  • Get down to the child’s level, or equal level for an adult
  • Do not shout
  • Be clear and use simple words

Working together to tackle behaviour which is challenging

Guidelines for formulation and problem solving workshops to tackle behaviour which is challenging
Template positive behaviour support plan

 

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