FAB Strategies John Pagano, Ph.D., OTR/L

Frequently Asked Questions from Therapists: Severe Behavioral Challenges

     1. Where do I begin as a clinic therapist with a 2-year 11 month old who is frequently screaming and won’t participate at all in my treatment sessions? If I bring him to his parents in the waiting room he does it more next time, but the screaming bothers other therapist’s clients and I’m not accomplishing anything anyway.

The first step is to find a sensory coping room with one or two activities the youth likes where you can calm the child so he is safe and doesn’t disrupt the other clients (even if this means initially reducing the treatment demands). It is often helpful to designate one treatment room a sensory coping room (one small room kept empty for when clients get upset that is as far away as possible from the other treatment rooms and has no moveable furniture, electric outlets or unlocked toys as well as a hard mat). Give him a break in that room to calm down, you can present one favored activity if it does not over-stimulate the child. During sessions use proprioceptive input to orient the child to the top and bottom, front and back, and two sides of their body. Also consistently use trauma informed care practices as a precaution (see question 2).

Immediately begin during sessions to find the student’s reinforcers. You can send questionnaires home or to teachers asking for things the student enjoys, or just try various things. Try to find level 3 reinforcers (e.g., things the child will do anything to obtain), level 2 reinforcers (e.g., things the child will work for) and level 1 reinforcers (e.g., things the child likes but will work not work too hard for). Two ways to test preferences for level is to see which of 2 choices the child wants, or giving him 5 objects for five minutes and see how long he plays with each one. Use reinforcers as initial activities for participation in therapy, and as reinforcers that immediately follow appropriate behavior.

  1. What is trauma-informed care and how do I apply it in my therapy sessions?

Trauma-informed care assumes that every client could have a history of Post-Traumatic Stress Disorder and consistently applies strategies that are sensitive to this possibility. I use several trauma-informed care strategies consistently with all of my pediatric clients and their parents, and find it helpful. Some strategies I consistently use:

a. Always ask permission before using touch by asking can I touch you? Never touch clients without permission. Not only does this practice assure you don’t upset clients, but it is good modeling for youth with poor physical boundaries around touch, modeling to prompt kids not to touch others unless they have gotten permission.

b. Give choices. This not only is helpful for empowering clients needing trauma-informed care but is a proven strategy to improve behavior. To maximize therapeutic benefit you can assure that both activity choices address the same therapeutic need (e.g., wall pushups or wheelbarrow walking to provide deep pressure through both shoulders) or have the client choose every other activity. Choices should also be given around discipline such as saying when a child is unsafely running, “Do you want to walk next to me or do you want me to hold your hand”?

c. Because discipline and behavioral practices are sometimes needed I start by pointing out: “I will always like and value you as a person, no matter what you do. Some of your behavior I will reward because they will make you successful in the future, and some things you do I will give you consequences for because they will cause you future problems”.

d. Orienting is a trauma-informed care practice that is especially important if you often have to alternate treatment rooms. Have the client facing the door and begin the session by playing a room orienting game. First have kids rotate their head from left to right, and if they are able progress to moving just their eyes with head stationary from left to right. Have them identify as they turn from left to right particular colors, shapes, or things from nature (wooden objects). This enables the child to get used to the room, and provides EMDR-like eye movements from side to side.

e. When doing activities like mindfulness and memory games that work best with the client closing their eyes offer eyes open or closed as choice options, as eyes closed can trigger kids with PTSD. I say, “you can close your eyes to make this game more fun, but I’m going to keep mine open to keep you safe”.

f. Allow students to ask the teacher to immediately call the therapist for an emergency break when they feel they will make a bad choice if they don’t get out of class (Blaustein & Kinniburgh, 2010). Teachers were fearful kids were doing this to get out of work, but upon offering it we found they stopped using it as they gained self-control.

  1. Help, I have a new school client on my clinic caseload who is severely developmentally delayed, bites and pulls hair? It is especially a problem in the waiting room (bad for business).

In addition to having a sensory coping room, doing preferred activities, reinforcing appropriate participation, and using trauma-informed care (as described in question 1 & 2) address transitions both environmentally and behaviorally. Reinforce the client for safe hands (going progressively longer without hitting others) and physically redirect the student to a preferred activity when they are hitting (LaVigna & Willis, 2012). Take a baseline before and after implementing this strategy to assure it is affective. It works because you reinforce students more when managing their hitting for safety in alternative ways, and are simultaneously reinforcing them for keeping safe hands.

  1. My use of sensory strategies appear to be increasing my client’s behavior problem, why and what do I do?

This is an indication that the behavior program is ineffective and should be changed. Begin by doing a QABF (Questions About Behavioral Function), Sensory Profile and preference assessment. These give information regarding the sensory setting events, the function of the problematic behavior, and the client’s most desired reinforcers. The QABF will indicate if the behavior is being done for sensory non-social, to get tangibles, escape, expressing physical illness, and/or for attention.

For example if a child is head banging, I answer the QABF in regards to head banging. If the goal of the head banging is to get attention and a therapist using sensory integration provides deep pressure with individual attention in a head massage immediately after the child does head banging, this can accidentally increase incidences of problematic head banging (Lydon et al., 2017). However, if the primary goal of the head banging is non-social (e.g., sensory, automatic) try to determine their sensory need and find a less problematic way to meet the need (e.g., giving head crown massage pressure on the head and a rocking chair), a proven strategy called Non-Contingent Reinforcement with a matched sensory input (Stahmer et al., 2016).

  1. If a child or adolescent has several behavior problems but you only treat them one-half hour weekly, which do you address first?

Start by addressing the most functionally crucial behavior problem, which is usually aggression towards peers. Once this is addressed, target physical aggression toward adults. Then move on to progressively addressing physical self-aggression, verbal aggression, and extremely limited attention span.

References:

Blaustein ME, Kinniburgh KM. Treating Traumatic Stress in Children and Adolescents. New York: Guilford Press; 2010.

LaVigna GW, Willis TJ. The efficacy of positive behavioural support with the most challenging behaviour: The evidence and its implications. J Intellect Dev Disabil. 2012;37(3):185–195.

Lydon H, Healy O, Grey I. Comparison of behavioral intervention and sensory integration therapy on challenging behavior of children with autism. Behav Interv. 2017;32(4):297–310.

Stahmer AC, Suhrheinrich J, Rieth S. A pilot examination of the adapted protocol for classroompivotal response teaching. J Am Acad Spec Educ. 2016;119:139.