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Coping with challenging behaviors

VIEWS: 47 PAGES: 60

									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         •   Eloping or Wandering
•   „Losing‟ Important Things   •   No solid sleep time
•   Getting Lost                •   Getting „into‟ things
•   Unsafe task performance     •   Threatening caregivers
•   Repeated calls &            •   Undressing
    contacts                    •   Being rude
•   Refusing                    •   Feeling „sick‟
•   „Bad mouthing‟ you to       •   Striking out at others
    others                      •   Falls & injuries
•   Making up stories           •   Infections & pneumonias
•   Resisting care              •   Seeing things & people
•   Swearing & cursing          •   Not eating or drinking
•   Making 911 calls            •   Contractures & immobility
•   Mixing day & night
•   Shadowing
   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
                             Early         Late
       Normal                Alzheimer’s   Alzheimer’s   Child




G. Small, UCLA School of Medicine.
        So… what is happening?
• Memory damage                    • Language damage
  –   Can‟t learn new things         – Has very concrete
  –   Forgets immediate past           understanding of words
  –   Does time & space travel       – Misses 1 our of 4 words –
  –   Uses old memories like new       may miss “Don‟t…”
  –   May not ID self or others      – Word finding problems
      correctly                      – Word salad problems
  –   CONFABULATES                   – COVERS
  –   Follows visual cues            – Follows your cues
  –   Seeks out the familiar         – Gets very vague & repeats
  –   Can get stuck on an old        – Uses automatic responses
      emotional memory track         – Mis-speaks
          So… what is happening?
• Impulse Control Problems           • Performance Problems
   – Say whatever they are             – Thinks they can do better
     thinking                            than they can
   – Swear easily                      – Can sometimes DO
   – Use sex words or racial slurs       BETTER under pressure –
     when stressed                       sometimes worse
   – Act impulsively                   – Uses old habits
   – Not think thru consequences       – Attempts can be dangerous
   – Can‟t hold back on thoughts         or fatal
     or actions                        – They will tell you one thing
   – Responds quickly & strongly         and then do another…
     to perceived threats              – Families may over or under
       • Flight, fight, fright           „limit‟ activities
  How do these losses relate
   to some risky behaviors?
• Persistent „going‟              • Lost and „Looking‟
    – inability to terminate         – can‟t find places
    – not able to anything else      – looking for familiar
    – discomfort                  • Invading space
• Eloping - escaping                 – automatic actions
    – following cues                 – following interests & habits
                                     – no awareness of „personal
    – wanting to leave
                                       space‟
    – going somewhere
                                  • Shadowing
• Constant talking or                – looking for help
  vocalizing                         – Comfort
    – Trying to communicate       • Resisting care
    – Self-stimulating               – Self-care
• Lack of Initiation                 – Movement
    – Won‟t move or cooperate
    Level 5 - Routines & Repeats
                          Diamonds
•   Word finding problems       • Becomes anxious and
•   Logic problems                frustrated easily
•   Place & time confusion      • Has trouble with new
•   Very „independent‟ or         routines and locations
    seeking constant            • Tries to maintain control &
    reassurance                   social behavior
•   Resents take-over           • May try to escape/leave
•   Self-awareness varies       • Can use signage & cues
•   Fearful about what is       • Gets „turned around‟
    wrong                       • Momentarily „disoriented‟
•   Typically resists outside   • Does regular routines JUST
    helpers                       FINE!
       Level 4 - Task Oriented
                       Emeralds
• Has trouble sequencing    • Uses visual information to
  thru tasks & activities     figure out what to do
• Often skips steps         • Follows samples & demos
• Looking for what to do    • Can‟t do an activity if visual
  and where to be             prompt is not there
• Believes they can do it   • Specifics and content in
• „Don‟t need your help‟      speech can be limited
• Has a mission in mind     • Gets stuck on „stuff‟
• Goes back in time         • Needs to be involved
• Gets lost in place        • Looks for „stuff‟ to do
  Level 3 - Hunting & Gathering
                        Ambers

• Uses hands to touch,       •   Imitates actions – copies you
  feel, handle, hold         •   Tool use is challenging
• Explores what is visible   •   Follows others
  and hidden                 •   Investigates the environment
• Invade other‟s space to    •   May taste or eat what they
  explore                        see
                             •   Difficulty terminating
• Repeats actions over
  and over                   •   Difficulty getting focused on
                                 care tasks
• Sees in pieces not whole   •   Becomes easily distressed
• Impulsive or indecisive        with unpleasant tasks
• Understands few words      •   Asks ?s mechanically
         Level 2 - Stuck on GO
                        Rubies
• Gross motor only            • Can‟t stop or sound
• Poor finger use               asleep
• Limited visual processing   • Copies your mood –
• Very limited                  facial expressions
  communication skills        • Can‟t grade strength
• Unable to do more           • Better with rhythm and
  complex motor actions         repetitive movements
• Imitates those around       • Loses weight
• Problems with chewing       • On the move – wanders
  and swallowing                forward – no safety
                                awareness
       Level 1 – Reflexes Rule
                       Pearls

• Bed bound or chair bound   • Swallowing and eating
• Unable to sit up for any     problems
  length of time             • Muscles shorten and
• Unable to communicate        contractures forms
  verbally                   • Pressure areas develop
• Lots of reflexes             because of no movement
• Breathing changes            & limited intake
• Moments of being           • Responds to touch, voice,
  present                      movement, smells
• Can make eye contact &     • Startles easily
  some automatic             • Motor agitation indicates
  responses                    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
       Something
  Form 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        •   use props or objects
• ask a person to help       •   gesture
  you                        •   demonstrate
• give simple positive       •   guide
  directions - 1 step at a   •   distract
  time
                             •   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
            REMEMBER
     Explore 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!

								
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