Difficult Behaviors Decoded
An expert offers advice for curbing difficult resident behaviors by understanding their causes and reacting in more effective ways.
Loud screams echo in the hallway. A nurse’s attention shifts from the chart she was working on to the room from which the screams are coming. She runs toward the resident and provides verbal reassurance, coupled with physical comfort of rubbing his arm and shoulder. The screams cease. The nurse walks away and resumes charting when the screams echo again.
This scenario routinely occurs in long term care settings, with many challenging behaviors such as screaming out, aggression, and sometimes hitting. Such behaviors can increase over time, with staff often habituating a behavior-response pattern. The Functions Of BehaviorBehavior is everything that a person does. Waving hello, walking down the street, talking to a neighbor are all behaviors. These behaviors serve as a function for an individual: waving hello to gain the attention of anther person, walking down the street for exercise, and talking to a neighbor for social interaction. Residents in long term care settings may exhibit maladaptive behaviors such as verbal abuse, physical aggression, elopement, noncompliance, or socially disruptive behaviors for a purpose, a specific function. Determining the function of the behavior will help staff assist the resident in exhibiting positive behavioral repertoires. From an applied behavioral analysis perspective, there are four functions of behavior. The most easily understood function is attention. In the example above, loud screams echo the hallway from a resident. The staff response is to approach and provide physical and verbal comfort. The screams cease when attention is given. The screams reemerge once the staff member has left. This interactive exchange between the resident and staff has taught the resident that by screaming, he will gain staff attention, and when the screaming stops, the attention stops. This behavior response pattern will increase the likelihood of the behavior of screaming to become more frequent. The second function of behavior is called escape. Demands placed upon a resident, such as showering, taking medicine, or changing clothes, can be viewed as aversive, which can manifest into verbal abuse or aggression. These behaviors serve as a function to ultimately escape from the desired task. The most common scenario is when staff are delivering care. A resident may often yell or strike out in an attempt to terminate and “escape” from the activity. If the response from staff is to stop the activity, the resident is more likely to continue to strike out during care to escape. The third function of behavior is tangible. Residents often yell, curse, or strike out at staff when access to a particular tangible item is limited, such as the desire for more food at mealtime. The last function of behavior is sensory. This occurs when the behavior serves as an automatic reinforcement independent of the environment. The resident’s behavior is self-stimulatory, such as scratching oneself. Preventing Reinforcement So how can staff effect behavioral change? Well, it could be as obvious as staff giving a directive, or it can be as obscure as fixing a crooked painting on the wall. While there are many variables that may influence challenging behaviors like these, including genetics, physical limitations, biological needs, and others, what is often not realized is that the environment—in this case, the staff’s reaction to the challenging behavior—plays a vital role in the resident’s behavior and, more importantly, can increase the future likelihood of the behavior. This process is called reinforcement. Reinforcement is a consequence that influences behavior. It increases the likelihood that the behavior will occur again under those similar conditions Data paint a picture. Data give the what, when, where, and how regarding a behavioral event. The “what” is what most people focus on, such as what happened? Staff might interpret this as “he struck the CNA [certified nurse assistant].” But is that the whole picture? Does that really describe what happened? To be more specific, it is best to know what happened right before the resident exhibited the behavior. Something in the environment set up the event that compelled the resident to strike the CNA. This is a key component in understanding resident behaviors. Whatever it may be, having data to interpret will help put interventions in place to reduce challenging behaviors. How does one know if something is reinforcing the behavior it follows? One of the best ways is to look at the ABCs of an incident: Antecedent, Behavior, and Consequence.
This is from Provider OnLine Magazine