Behavior or Sensory? Understanding Challenging Behavior

Editor's Note: This text is an edited transcript of the webinar, Behavior or Sensory? Understanding Challenging Behavior, presented by Tara Warwick, MS OTR/L.

Introduction and Background

Working in early childhood with young children is a challenging behavior.  As an OT, I am often asked if it is behavior or sensory.  My response is usually, "Yes, it's probably both." This course will walk us through a framework for looking at behavior objectively. Even if it's coming from more of a behavior or a sensory background, it doesn't matter because this framework will help us really look at the "why" behind the behavior.

The agenda for this course is to describe the challenging behavior, collect objective information about the behavior, form a hypothesis (our "why"), create a plan looking at preventative strategies and skills to teach, and evaluate that plan.

"You can't teach children to behave better by making them feel worse. When children feel better, they behave better." (Pam Leo, Connection Parenting) This is a great quote by Pam Leo.  We want children to be happy.  We want them to want to be at school and we want them to want to be in our therapy sessions. We want them to be happy because if they're not, then they're not learning. So we have to start with meeting them where they are and finding what they enjoy in order to really change behavior.

What We Know

Looking at the research, we know that within the context of school, children who exhibit challenging behaviors are considered at increased risk of academic failure, delinquency, dropping out, gang membership, and adult incarceration (Dunlap, 2006). So challenging behavior is a big deal. It is something that we need to address when children are young.  We also know that if children are in high quality classrooms, that decreases their chance of these things happening. Therefore, we have to consider the classroom environment and really help decrease challenging behaviors. 

Common Behavioral Pitfalls

There are some problems or pitfalls to be aware of if a person comes from a strictly behavioral background or behavioral perspective.  Rewards are used as bribery and might not be given enough. For example, if a student is good all week then they can have computer time on Friday. It's possible that the reward is not meaningful. We shouldn't be giving a child stickers if that means nothing to them.

Time outs or consequences are not used appropriately and too often. This is happening more and more in the schools.  Time outs are being used but they are not changing the behavior.  Students are being put into time out over and over again and it is not working. It's not punishment for that child.

We often reinforce the "wrong" behavior.  If the behavior keeps happening, somehow we're reinforcing that behavior. Additionally, we might not take into account the sensory preferences of the child if we are only looking at things from a behavioral background or perspective.

Common Sensory Pitfalls

If behavior is only looked at from a sensory perspective, there are pitfalls to be aware of as well.  For example, implementing strategies without thinking about the "why." Meaning, we don't look at the behavior objectively and, instead, say, "Oh, they're running around in circles. Let's give them a fidget toy."  Another pitfall is starting with the sensory strategies before looking at environmental strategies. Sometimes I hear teachers say, "Well, he just has sensory issues," which really takes the behavior and puts it all on the child rather than looking at the environment and determining what environmental changes should be put in place.  Additionally, implementing sensory strategies only during an OT session is another sensory pitfall.  We have to look at how to incorporate those OT supports throughout their day.  Another sensory pitfall is when the plan doesn't change when the strategies do not work. We implemented a strategy and it didn't work so we stopped.  Finally, following a strictly sensory approach is sometimes a way to avoid addressing other environmental factors. 

How Do We Work Together?

We have to take our judgment out of the behavior. We need to take a step back and look at behavior objectively for what it is. It is communication. There's a reason behind it. I had a special education director tell me that behind every challenging behavior is a positive need. The child is trying to tell us something. Whether they are highly verbal or highly nonverbal, behavior is behavior and there's a reason behind it. Therefore, we have to be the "private investigators" who dig down and find out the "why" behind the behavior.

Behavior continues because it's reinforced.  If a behavior keeps happening it is because the child is getting something out of it. We have to look at what else we want them to learn and to use. Instead of focusing on not wanting the child to hit anymore.  Think about what you would like them to do instead. What other skill do we need to teach them?

We have to address environmental concerns. Do we need to add more structure? Do we need to teach more routines or procedures? What do we need to do in the environment to avoid some of those challenging behaviors?

Positive Behavior Supports

The concept of positive behavior supports is research-based and is the bridge between these approaches that helps us stay more objective. With limited time and resources, we have to use what is supported by research. Positive behavior supports focus on data-based decisions, the environment and replacement skills. PBIS.org is a great resource for information on positive behavior supports.

Challenging Behavior

Challenging behavior is defined as "any repeated pattern of behavior or perception of behavior that interferes with or is at risk of interfering with optimal learning or engagement in pro-social interactions with peers and adults (Smith & Fox, 2003)." In other words, it's any behavior that's interfering with the student's ability to be the best they can be at school, at home or in the community. When a behavior is interrupting that, it needs to be addressed. This is not referring to just those obvious behaviors such as hitting, biting and kicking.  Most of the children who are overlooked are the ones who have checked out - that is a challenging behavior too. That type of behavior is often not addressed because it is not interfering with what we need.  However, it needs to be recognized as a challenging behavior too. 

Behavior = Information

Behavior is information and we are going to look at behavior for what it is.  We are not going to look at behavior as good behavior or bad behavior.  Rather, it is just behavior, what is happening around it and what is the child trying to tell us with that behavior. This is more of an objective process.

Consider the following quote: "Perhaps his behavior has not changed because your behavior has not changed." In order to change the challenging behavior, we have to change. Yes, we are going to target children and teach them new skills, but if we truly want behavior to change, we need to do something different.  People will say, "I don't have time. I have 20 other children I need to see."  My response to that is, "You're putting the time in already. I guarantee if you were to clock how much time you're spending with that child in the meltdown or with the behaviors, you've already given the child the time. So let's do it in more of a proactive way."  We want to put some preventative strategies in place and teach replacement skills.

Identify the Behavior

First, identify the behavior by describing it in a way that is observable.  The idea is to pick only a couple of behaviors and to avoid words such as "meltdown," "aggressive," or "disengaged" because it is hard to know what those look like.  Disengagement can look very different for some kids than1 it does to other kids. Instead of saying meltdown, I might say, "He goes to the floor and he kicks the floor." That's something that anybody can see. Instead of aggressive, I could say, "He hits other kids. He hits adults. He tears up his work." Instead of using the phrase, "work refusal," I could say that the child does not respond to an instruction within five seconds."  That is measurable. 

It's important to remember to not hypothesize at this time.  We are not considering the "why" yet, we are first looking at the components of the behavior.  As an aside, during a recent school training, I asked the participants to give an example of a challenging behavior.  A teacher said, "He is tearing up his work.  He doesn't want to do it and he is refusing to do it." All of this was said as her Step 1 of "identify the behavior".  I explained to her that she was already moving to the hypothesis so she stepped back and said, "He is tearing up his work." Again, Step 1 is to just identify the behavior.  

Here is an example: "When transitioning from breakfast in the morning to rug time, Jacob will run around the room until the teacher can physically stop him. When she stops him, he starts hitting and kicking her until she takes him in the hallway, sits him down, and makes him wait." The first behavior would be running around the room and the second behavior is hitting and kicking her.

Here is another example: "During free play time, Sam will walk up to the puzzles, and throw the puzzle pieces at peers until the teacher takes him to a table by himself. When he is at the table by himself, he will start screaming at the teacher until he is removed from the classroom and taken to the principal's office." The behaviors would be throwing the puzzle pieces at peers and the other one is screaming at the teacher. Those are the two behaviors that should be addressed in this situation. Again, I am not looking at the "why" yet I'm just describing the behavior.

Objective Information

The second step is looking at the components around the behavior.  What happens before the behavior and what happens after the behavior. There is a great quote that says, "The biggest communication problem is we do not listen to understand, we listen to respond."  As a consultant, over the years I would go in to see a teacher or family about a student and I would ask if they have tried this idea or that idea.  I'd get so excited.  I've had to learn to really slow down, and instead of just responding and giving answers, I've had to listen and really understand what's going on.  Step 2 helps us better understand the behavior when we have all the components of the behavior.

There are various ways to obtain objective information:

• ABCs of behavior
• Collecting data
• Motivational Assessment Scale
• Sensory based checklists

ABCs of Behavior

I am looking at what is happening before (antecedent) and after the behavior (consequence).  The antecedent is what happens before the target behavior. It could be an event or something in the environment.  For example, maybe a student got off the bus. Maybe they took away the iPad. Maybe they were waiting to go to PE. Maybe I told them to do something.  Those are antecedents and there is always an antecedent.  I often hear, "We weren't doing anything.  We were just sitting there and he hit me."  My response is the antecedent was that you were doing nothing with them.  A lot of behaviors happen during wait time. So the antecedent is when he was waiting. When he had nothing to do. 

The consequence should not be thought of in terms of "good" or "bad", it is simply what happened after the behavior.   The group that I was working with recently said that they tried several ideas and they didn't think they were right. I had to explain to them that I didn't want them to judge themselves. Rather, just describe what happened afterwards.  Did you take away something? Did you verbally redirect them? Did you put them in time out? Did you give them what they want? Did you remove them? Did you give them a break? What did you do after they did the behavior?

With that, we can start thinking about what happened to the behavior when I respond a certain way.  When I responded this way, the behavior improved. When I responded this way, the behavior got worse.  Knowing this information will help to create a good hypotheses as to why the behavior is happening.  For example, when I took the student out of the classroom, the behavior stopped. That's telling me that maybe they want me in the classroom.  When I ignored the behavior, it got worse or when I gave them more attention, it got better. All of those things, the consequence, helps to determine why the behavior happened.

Identify the components. Consider the following example. When transitioning from breakfast in the morning to rug time, Jacob will run around the room until the teacher can physically stop him. When she stops him, he starts hitting her and kicking her until she takes him in the hallway, sits him down, and makes him wait. The behavior in this scenario is running around the room. The antecedent is transitioning from breakfast to rug time. When the class is transitioning into the classroom, he runs. His behavior is he runs.  The consequence is that the teacher chases him and tries to physically stop him. 

The second part of this scenario, following the ABC model, the antecedent is when the teacher physically stops Jacob.  The behavior is Jacob hitting and kicking her. The consequence is the teacher when takes him in the hallway, sits him down and makes him wait, and the behavior stops. What is Jacob trying to tell us with that behavior?  What is stopping the behavior?

Gathering the Data

Here are some ABC data examples. I highly suggest that if you are having a lot of challenging behavior then look at how you're writing that down. Many times, teachers use journaling, which might be the school's policy.  However, journaling can be too subjective. It takes a lot of time that nobody has, and it can allow for too much emotion.

Figure 1 shows an ABC data example. The antecedent is circle time, the behavior is kicks other student, and the consquence is goes to time out. The possible function, which is going to be the next step, is that the student might be doing it to escape. This table is one way to keep some ABC data.

Figure 1. ABC data example.

There are many different ways to collect data.  I knew a teacher who would put a piece of masking tape on her leg and she would mark on the tape how many times the student did the behavior in a certain activity. Then, at the end of that activity, she could see how many times he had that behavior.  You can move bracelets from one arm to the other. There are lap counters. I've had students do some self-monitoring where they would give themselves 1-5 ranking for how they were during an activity.

Figure 2 is another data collection example.  The left side of the figure shows what the teacher recorded.  There were pictures of the child's schedule and then they drew happy faces and sad faces for each activity.  (I was not really in agreement with that, but that is what they chose to do at the time.) The right side of the figure shows how I transposed the happy and sad faces to a number and counted up how many times in a week each behavior happened for the different activities.  Then I could see if there were certain times that the behavior was more likely to happen.  

Figure 2. Data gathering example.

I have also collected data by using a list of the child's routines and having the teacher rank on scale of 1-5 how likely the behavior is to happen for each routine. Routines that were ranked high might indicate a time that warrants more specific data collection for that behavior.  Also, seeing which routines do not cause the behavior can be very valuable information as well.  

Motivation Assessment Scale

This is a great checklist that can be used to collect data and can also help to form a hypothesis.  You choose a behavior, such as hitting, to answer all of the questions about that one behavior.  For example, Would the behavior occur continuously, over and over, if this person was left alone for long periods of time? With hitting, they are probably not hitting if they're left alone. So that question would be scored a zero. Once all of the questions have been answered, it gives a total score.  Whatever the highest total is, the tool offers some possible reasons why.  It could be sensory, tangible attention escape, etc. and which ever of those reasons receives the highest score that is the most likley reason for the behavior.  This is a great tool to use for behaviors, especially if you're not around the child a lot, if you're more of a consultant or if you're working on creating a functional behavior assessment. 

Sensory Checklist

This is another type of checklist used to identify sensory preferences within the child.  Figure 3 shows a list of those sensory preferences.
 

Figure 3. Sensory checklist.

There are various sensory processing disorder checklists and there are some specifically for preschool. Again, these checklists can help determine what a child's sensory preferences are and what kinds of supports they might need.  Some people need more sensory input and some people need less input. The sensory profile is a great tool to use too. If you have an OT on your team, they can help do the sensory profile on a child to assess their sensory needs.

Forming a Hypothesis

To summarize, first we identified the target behavior as hitting, which is an observable and measurable behavior.  Second, we determined the antecedents and the consequences of the behavior.  What's happening before the behavior and what's happening after? The antecedent might be that I gave a student a math worksheet. The behavior was that he tore it up. The consequence was that he went to time out and the behavior stopped.

Based on that information, what is the hypothesis? Never start an intervention without formulating a hypothesis. Any time we start something, think about why we're starting it.  For example, we might start an intervention because we are putting a visual schedule in place. Before starting that visual schedule, I'm thinking about the ABCs, and I am thinking that this behavior is happening because he doesn't know what's coming up in his day. If that's my hypothesis, my strategy is going to be the visual schedule. The hypothesis determines the intervention.

"There are two possible outcomes to a hypothesis. If the result confirms the hypothesis, then you've made a measurement. If the result is contrary to the hypothesis, then you've made a discovery (Enrico Fermi)."  A hypothesis is a guess as to why the behavior is happening. A guess is a lot stronger with the more data we have.  If we have ABC data on the last 20 times the child demonstrated the behavior, and our hypothesis is based on all of that data, then our hypothesis is going to be pretty strong. If the hypothesis is formed around one time that the child demonstrate the behavior, then it might not be that strong of a hypothesis.  The data that we're collecting helps build the strength of the hypothesis, which in turn, determines what intervention we are going to use.

Thinking about the hypothesis, what is the student getting or not getting out of the behavior and why does it keep happening? When planning treatment, we start with a hypothesis and there is no right or wrong answer until we test it.  Keep in mind that there is the possibility of multiple hypotheses for one behavior. For example, we might have a child that scratches everyone and that behavior means 10 different things. Sometimes it means she needs a break, sometimes it means she is bored, sometimes it means she wanted to take pictures with her camera, but it wasn't available to use.  It is also possible to have 10 behaviors for one hypothesis.  Meaning, maybe a student hits, bites, scratches, kickes, and runs around naked.  All of those behaviors mean they're trying to tell us that they need a break.

Every behavior happens for two reasons, either to get something or to get away from something. This is true for all behavior, not just children's behaviors. Every person's behavior happens for a reason. Maybe I'm trying to get someone's attention, maybe I'm trying to get something tangible, maybe I'm trying to get a sensory needs met or maybe I'm trying to get away from someone's attention.  Perhaps I am trying to get away from something tangible or something sensory. Therefore, when thinking about the hypothesis, think about it in the format. What is the person trying to get or what are they trying to get away from?  

How to Formulate

In order to formulate a hypothesis consider if there is enough objective information. Do I have enough of those ABCs? Have I filled out the checklist? Do I have enough data and objective information to support the hypothesis?  Make some conclusions about the behavior such as conclusions about the antecedents, the consequences and the sensory needs. What makes the behavior stop?  For example, if I take away all of the student's math, he stops the behavior.  Maybe he's trying to tell you that math is too hard. When I ignore him and don't give him any attention, the behavior gets worse. Maybe he's trying to tell me that he needs my attention. Those are the types of things we need to think about as we're creating the hypothesis.

Analyze antecedents.  We want to look at the antecedents; those things that happen before the behavior. We want to look at what prevents the behavior as well as what triggers the behavior (Figure 4). 

Figure 4. Analyzing the antecedents.

When I prepared him for a transition, the behaviors decreased. When I gave him something to do while he was waiting, the behaviors decreased. When I reminded him of those expectations, those prevented the behavior. However, the antecedent that triggered the behavior was anytime he had to wait, when activities were unstructured, when there was a new activity or when I took away a reward. Those were all things that trigger the behavior.  Again, this is how to analyze those antecedents.

Analyze the consequences. Consequences can also be analyzed.  For example, figure 5 shows the consequences used over the past two weeks. I did time out, I took away a reward, I did some verbal reprimand. When I gave him a time out, the behavior stopped for the time being, right? I'm not saying that consequence worked, I'm just saying it stopped it in the moment. However, he kept going back to time out.  When I took away a reward, the behavior got worse. When I did a verbal reprimand, the behavior got worse.

Figure 5. Analyzing the consequences.

How can I analyze the consequences to see which ones are working? Meaning, which consequence stopped the behavior?  The goal is to be able to meet the needs of the child so they don't have to do the behaviors anymore. That is where our intervention plan comes into play.  But, we first have to think about what they're trying to tell us. If they're trying to tell us that math is too hard, we're not going to put him in time out anymore.  Instead, we change the antecedents and the consequences so the child doesn't tear up his math paper anymore to get out of math. 

Analyze sensory needs. Based on the sensory processing model by Winnie Dunn, we are going to look at a high threshold and a low threshold.  A high threshold means that the person needs a lot of sensory input.  Think of it as having a big beaker that needs a lot of input and I am either active or passive in that.  If I need a lot of input, and I am active, that means I am constantly trying to fill it up.  If I am passive then I kind of "melt" into the system or melt into my chair.  I need the input but I don't know how to get it.  

Having a low threshold can be thought of as having a small beaker.  I don't need much information before I am overloaded.  If I am active with a low threshold then I am constantly avoiding or running away from things because it is too much for me.  If I am passive with a low threshold then I tend to get very distracted.  With that in mind, does the child have a high threshold or a low threshold for sensory information?  Is it possible to have different thresholds for different types of sensory information? For example, maybe a child has a high threshold for movement and needs a lot of proprioception activity or a lot of vestibular activity.  However, they have a small threshold for their auditory. So if they hear a lot of things going on, it's overwhelming to them and they lose it, but they still need a lot of movement. It's important to think about analyzing threshold in our students. 

Writing a Hypothesis

When writing a hypothesis, use the following: "When ______, the student may ______ in order to _____.  For example,  "When presented with difficult math, Jacob might pinch until the teacher removes the work." Another example, "In order to gain sensory input, Jonathan might squeeze his paraprofessional to get deep pressure."

If the above hypothesis is, "Presented with difficult math, Jonathan might pinch the teacher until he removes the work," then I need to think about how to modify the math and how to provide more reinforcement when he's doing difficult math because I don't want him to pinch anymore.  If I don't change the math, then he's going to keep pinching me which could turn into something else. If the behavior is happening to gain sensory input, he might squeeze his paraprofessional. I am going to help him get input without having to just go up and squeeze his paraprofessional. I am going to either teach him how to ask for that or I'm going to teach him how to get that sensory need met in other ways. Again, this hypothesis will guide the intervention plan.

Example: When transitioning from breakfast in the morning to rug time, Jacob will run around the room until the teacher can physically stop him. When she stops him, he starts hitting and kicking her until she takes him into the hallway, sits him down, and makes him wait.

The hypotheis for this scenario might be that he is trying to escape rug time. So, what should I do?  I am going to think about rug time and how I can make it better.  Why doesn't he want to sit there? How can I put more reinforcement into rug time? How can I make it more structured?  Can I teach him how to ask to get out of rug time instead of running around? Maybe I have a card that he uses to get out of rug time and instead of me chasing Jacob, if he gives me the card, he can get out of rug time.

Example: During free play, Sam will walk up to the puzzles, throw the puzzle pieces at peers until the teacher takes him to a table by himself. When he's at the table by himself, he will start screaming at the teacher until he's removed and taken to the principal's office.

In this scenario, Sam may be trying to tell us that he doesn't know what to do with the puzzle pieces.  As mentioned earlier, there could be five different hypotheses for this behavior.  But I am going to hypothesize that he is trying to tell me that he does not know what to do of the puzzle pieces and he is wanting somebody to play with him. If that's the case, then my intervention plan might be to teach him how to play with the puzzles. I am going to give him that attention right away and help him do the puzzles.  Then, maybe I also teach him how to ask for a break. I will put into place some replacements skills and preventative strategies so that he doesn't have to do those behaviors anymore.

Creating the Plan

At this point, we have evaluated all of the components, we have thought about what helps the behavior, what makes it worse and when does it not happen.  Sometimes, the best question we can ask is, "When doesn't the behavior happen?"  If a student is doing the behavior all the time, it may be best to consider when does the behavior NOT happen?  Perhaps the student never has the behavior during computer lab or when I am giving him verbal instruction.  That information can provide ideas for what to do in other environments. 

The fourth step is to create a plan around the hypothesis and there are four essential elements that must be included.  1) Clarity - making sure it is very clear what we are going to be doing. 2) Consistency - the plan is consistent because children with challenging behavior need consistency. 3) Simplicity - making sure the plan is simple enough that anybody can be consistent with it.  4) Continuation - we can keep the plan going. It's not something that is impossible to continue doing.

The plan should help make things easier, not more difficult. Some plans take more work in the beginning, but that will make things better in the end especially for the child and their family.

Preventative Strategies

Preventative strategies, such as rituals and routines, visual supports, sensory supports, modifying expectation and modifying instructions are put in place before we expect anything to happen. Routines and rituals are two types of preventative strategies that are great to use in the classroom.  We are finding that behaviors happen in the classroom for all children, not just those with behavior challenges, when there is no routine or procedure in place.  Rituals and routines may include songs, rhymes, games, and kinesthetic movement that can be used to foster community and serve as rule reminders. These activities taught over time and embedded as part of a daily schedule serve as reminders to children about appropriate behaviors in different classroom contexts.  Rituals and routines can also provide stability and consistency and can communicate values such as friendship, caring, or responsibility. For instance, the teacher may teach a set of songs about these values that children sing at the end of circle time, or the class may always review the expectations when walking in a line to go from place to place (http://challengingbehavior.cbcs.usf.edu/docs/RecommendedPractices_preventing-challenging-behavior.pdf ). 

Why are transitions hard?  There are a lot of behaviors that happen during transitions. Are there too many transitions? Are all the children transitioning at the same time, in the same way? Is it too long? Are we trying to get 25 students to go to the bathroom at the same time? Is there too much waiting (Wait time is death time)?  Is there no clear instruction? Maybe we need to practice those procedures again.  Figure 6 shows one way to change the routine. 

Figure 6. Example of a routine change.

This article (www.imagineeducation.com.au/files/CHC30113/BTJ_20Moving_20Right_20Along_20Planning_Transitions.pdf) provides great resources for making routines more rich and meaningful. For example, instead of writing "Arrival/Handwashing" from 8:15, write "Arrival/Handwashing/Table toys" so the children have a choice of table activities. The revised routine allows children to come in and look forward to playing at the tables. This allows us to start identifying what the children are interested in while adding in those other routines. 

To help families with morning and bedtime routines, which can be very challenging, some tips for creating good routines and rituals around more family-type routines include:

• Morning routines 
  • Some bonding time in the morning
• Bedtime routines
  • Consistent bed times
  • Activities that are calm
  • Identify the plan the next morning
  • Give plenty of attention
  • Plan ahead for next morning
• Use picture schedules

Another great preventative strategy is visual supports such as picture schedules, cue cards for sensory breaks, visual timers, checklists and five-point scales. Typically, when I use a visual support, I talk less. For children with challenging behavior, the more we talk the more the behavior escalates.  It's important to use visual supports so we can decrease how much time we are talking.  Visual supports provide clear expectations and can significantly decrease challenging behavior.  A great tool is a dry erase board to do something as simple as create a list of tasks or activities: 

1. Game
2. Puzzle
3. Writing

A dry erase board could have five circles that are filled in each time an activity is completed.  Below is an example of a symbol chart and each symbol would tell the child which activity to go to. 

Figure 7. Visual support example.

Another visual I used with a family was to teach them how close the child needed to be (Figure 8).  

Figure 8. Visual support example #2.

Another visual support I have used is to have the child fill up their card with fish as they completed each station.  When all five fish were on their board they were done (figure 9).

Figure 9. Visual support example #3.

The image below shows boxes with different shapes on them.  The child would take whatever shape was on their schedule and match it to the correct box to work on the activity that was inside. 

Figure 10. Visual support example #4.

The time timer is also a great visual support (Figure 11). The idea is that when the red portion of the timer goes away, the time also goes away.

Figure 11. Visual support example #5.

Modifying activities and expectations would include:

• reducing the amount of work
• breaking the activity down into smaller steps
• talk less
• prompt them to get it right
• shorten time expectations

In schools, the majority of challenging behavior happens around academics and wait time.  How can we modify the academics so that those behaviors don't happen? Maybe cut the worksheet in half or have the student complete two items and take a break.  Really making sure we are helping the student get things right versus letting them make mistakes.  The more mistakes they have, the more likely that behavior is to happen. 

Here is another visual for breaking down an activity.  Each step is shown for doing an activity with Play-Doh (Figure 12).  This can also be done with legos or other types of manipulatives. 

Figure 12. Modifying acitivity example.

Sensory Supports

Sensory supports are preventative strategies. We're not looking at sensory as changing their sensory system; research does not support that idea. People are who they are and they're wired how they're wired, right? Therefore, we need to learn how to support different sensory processing styles and learn how to compensate when we have different sensory styles.

If the child has low/poor registration, meaning they have a big bucket, but they're not feeling it, then we are going to provide more intensity and support. We're going to structure and provide them more support throughout the day to keep them alert. If the child is sensation seeking, meaning they have a large bucket and they're actively seeking sensory input, we are going to structure that input.  If they are sensation avoiding (i.e., they have a small bucket) then we are going to provide more structure while teaching some flexibility. If they're sensitive to stimuli (i.e., they have the small bucket) we are going to provide structure, decrease stimuli, and provide a quiet place.  It is very important to understand the different sensory processing styles in order to provide appropriate support.

The BrainWorks App is a great way for children to show how they are feeling by clicking on different images. It can be programmed and there are suggested activities for helping the child when they are feeling a certain way (e.g., fast and stressed). 

Creating a quiet space (a break area) can be helpful for children who seek small, tight places. It is best to have a break area in the classroom, not down the hall in the OT room, but within the classroom.  A break area is different than reward time. It needs to be a neutral area. If the child loves using an iPad, don't let them to have it in the break area because why would they ever want to be in their work area? Those high reinforcers such as iPads are things they get when they do their work. A break area is meant to relax and get yourself back together again.

The following image is an example. Make it structured and use visuals for break time. Post a schedule of what the child should do along with a timer. 

Figure 13. Break area with schedule and timer.

It doesn't have to take up a lot of room in the classroom.  It is just a small area.

Figure 14. Examples of break areas.

Teach Alternative Behavior 

When implementing the plan, we are going to teach replacement skills such as communication skills, self-regulation, social skills, waiting, following directions and organizational skills. These are skills that often relate to challenging behavior and ones that we want the child to do instead of the challenging behavior. For example, we might be teaching students how to ask for a break. If your hypothesis is that they are trying to get a break, let's teach them another way to ask for a break. Even if the student is highly verbal, they might still need a picture because when a person is stressed, their IQ and verbal skills go down tremendously.

Communication skills include teaching them how to ask for a break or ask for a desired item.  Do they have a way to communicate what they want?  If they're doing the challenging behavior for attention, teach them how to ask for attention.  Can they tell you they're hurt and in pain? Many children with challenging behaviors have really poor interoception skills which is the ability to know how the inside of your body is feeling. Sensory perception is how you're feeling on the outside, interoception is knowing when you feel hungry, when you need to use the bathroom, when you are you tired. We want to teach them how to recognize those feelings.  Finally, teach them how to answer questions. 

Self-regulation skills include knowing when to take a break and how to take a break. Oftentimes, students with challenging behaviors don't even realize they need one.  They might not know when they are feeling stressed.  There have been times that I have actually had to teach children how to take a break.  And we didn't do it when they were upset, we did it when they were not upset so that they were comfortable with the break when they did need it. Using a five-point scale can be helpful for a child to communicate how they are feeeling. A score of five might mean the child is very upset and a one might mean they are really happy.  The scale can be color-coded.  I've had kids draw their own and we'll draw pictures on the side. You can incorporate their special interests.

There are some tips to follow in regards to breaks. Does the child know what they're supposed to do when they are in the break area? Again, this is different from reinforcement. It needs to be a calming structure, built into their schedule. At first, we want to give them a break whenever they asked for it to teach them how to communicate. But if they're starting to request a break all of the time, then perhaps something is happening that is reinforcing in the break.  Remember, reinforcement should be given only when they work for them.  A break is given to help with calming.

Another great way to help with self-regulation is mindfulness. Mindfulness is the idea of being in the moment and learning how to relax.  MindBodyGreen (www.mindbodygreen.com/) is a great website for mindfulness activities.  Mindfulness activities can be done throughout the classroom.

The Turtle Technique is also great for self-regulation (Figure 15).  It's a way to teach a child regulation skills, especially when they don't have a break area.  For example, when they're in public, this can help them "go into their shell" and think of what else they can do. 

Figure 15. Turtle Technique.

Social Skills

A lot of challenging behavior can occur around social situations.  Interacting with others and dealing with losing or rejection can be big triggers for children.  Some children need to be taught how to lose.  So often, we want to keep children happy and we want to teach everyone to be a good sport.  But we also need to teach them how to lose and to be okay with that because it is going to happen a lot in life. 

We may need to teach them how to join in on play and how to ask somebody to play. They may need to learn how to understand perspectives of another person and this can be really hard, especially for children with autism. They may need to be taught how to read cues of another person, how to read that they're not wanting to talk to you anymore, that they're frustrated and how to have back and forth conversations. Michelle Garcia Winner's website, socialthinking.com, is a great resource for teaching social skills, especially to kids who are on the higher end of language. It provides some good ideas for teaching kids how to think through social situations.

Helping a child with problem solving could involve the following steps:

• What is my problem?
• Think of some solutions.
• What will happen if I do this solution or that solution?
• I'm gonna give it a try.

Waiting

As mentioned earlier, wait time is death time. Waiting for a turn, waiting for a desired item, wiating to transition can all be very difficult for children with challenging behavior. It is best to start with waiting for something that doesn't matter as much. For example, when we teach preschoolers or even three-year-olds how to wait, we don't get out their favorite piece of candy and teach them to wait. We'll get out something they're okay with, and then we'll teach them to wait. We might physically hold their hand in their lap, tell them to wait and they'll hold their hand in their lap, and then we'll give them access to it. So they're really learning what that word means.

Following Directions

Activities may need to be broken up into small steps. They may need to be one step directions to start.  It may be as simple as 1) I will tell the child to stand up, 2) I will help him stand up and 3) I will praise him for following that direction.  Then, I can move on to more than one step.  Start with simple instructions and help them get it right after the first instruction. Don't teach them to respond to the third or fourth instruction, teach them to respond to the first one.

Organizational Skills

Students who are kind of "all over the place," may need some organizational skills. This might be with homework folders, their backpacks or their bedrooms. Help develop a strategy that fits into their routine. Using clear containers so they can see what items are in them can be very helpful.  Be sure to label the containers and keep referring to them frequently so the students learn the system.  Labeling a folder with "Leave at home" on one side of the folder and "Return to school" can help a student keep papers organized. 

Tips for Teaching Replacement Skills

When teaching replacement skills be sure to outline the steps. Handwashing is a good example.  It might be surprising how many steps there are to handwashing.  I need to stand up, push in my chair, go to the sink, turn the water on, press the pump, put soap in my hands, rinse my hands, turn the water off, get the paper towel, turn the water off, sit back down. There could be 12-15 steps for washing hands.  Be sure to look at what steps they need help with and then be there to help them and prompt them. What steps can they do independently? Then, put reinforcements in place.

Consequences

A consequence is anything that immediately follows as a result of a behavior. Consequences can either increase the likelihood of that behavior happening again, decrease the likelihood of that behavior happening again or have no effect.

There are three types of consequences: positive reinforcement, negative reinforcement and punishment. Positive reinforcement is adding something that makes the behavior happen more often.  Negative reinforcement is removing something after a behavior is happening.  A negative reinforcement might be when a student tears up their math paper, I take their math book away.  Punishment is a consequence that follows a behavior in order to decrease the likelihood of the behavior happening again.  Time out is usually thought of as a punishment.  But, maybe it is actually negative reinforcement.  The key is whether or not the behavior continues to happen again.  If it continues to happen then the behavior is being reinforced, either positively or negatively.

This is a great quote, "Every day may not be good, but there is something good in every day." We have to find ways to reinforce kids in a positive way.  The difference between positive reinforcement and bribery is positive reinforcement is giving them something to increase that behavior.  For example, a parent and child are at the grocery store and the child has a meltdown. The parent tells the child to get in the cart and I will give you this candy bar, just stop screaming. That's bribery. The parent is giving them something to stop a behavior.  What you want to do is give the child something to increase a behavior.  That is positive reinforcement.  It occurs after a desired behavior. 

Smaller, more frequent amounts of reinforcement is better. We can cut candy into eight pieces if that is what is reinforcing to them. I use pill cutters with M&Ms. Making the reinfocement intermittent, or more random, is also better. Bigger reinforcers are used for harder tasks. If the child is working on a brand new skill that's really difficult, use the things they like the most. It has to be individualized to each child and something they are interested in. 

More variety is better too. If a child only has one reinforcer, find more reinforcers because the current one could get satiated. If the reinforcer is used too much the child might not be interested anymore.

When someone asks how often should reinforcement be given, the 50% rule can be used.  The 50% rule splits the time in between activities or the time between behavior.  For example, during circle time, Johnny gets up and runs around every 60 seconds.  The 50% rule says to give him positive reinforcement after 30 seconds.  The 60 seconds is split in half and that is how often he needs some type of reinforcement.  

Finally, use visuals when possible. 

Delayed Gratification

Although we may start with reinforcing the child after ever time they do an activity, we want to eventually delay that or teach them delayed gratification.  This can be done by having the child sit for longer periods of time or wait for longer periods of time.  A token economy system, reward board, classroom rewards and point systems are all ways to teach delayed gratification.  Below is an example of a reward board. The child places a picture of what they are working for in the center of the board.  If the 30-second rule is being used, then the child would receive a star when they sit in circle time for 30 seconds.  After another 30 seconds of sitting at circle time, they receive another star and so on.  When they get all five stars, then they get access to their iPad.

Figure 16. Reward board as an example of delayed gratification. 

Tips for using a token system. Do not remove the tokens the child has earned. It is better to ignore the behavior and think about what we want them to do.  Pick a couple behaviors to target and best overall frequency is intermittent. Again, do random reinforcement so they're not expecting it every single time.

Reoccuring behavior. If the behavior reoccurs, start by redirecting the student to the visual.  If the behavior starts to escalate, use a reminder and say, "two more stars and you can have you iPad."  Use distraction with caution. It is great in the moment for one time or one activity.  But if distraction is used every time the behavior happens, then you don't have the right hypothesis.  If the child's behavior is escalating every time during math and we're starting to distract by giving him coloring, then that behavior is reinforced. Distraction is just to help in the moment. It is not meant to be used at long term.

If using "time out," then structure it.  Use time outs only if they are decreasing the behavior.  This doesn't happen much with the students that I work with because it is more about teaching the other skills.  Again, is it reducing the behavior or is it reinforcing the behavior? Is time out better than time in?  If I'm putting them in time out, every time I'm asking them to do something, most students would rather sit in time out and do nothing than have to sit at the table and do work that's too hard for them.

Escalation. If the student is showing signs of escalation, stop and think about what's going on. Restate the expected behavior. Keep your words simple. Really think about telling them what to do (e.g., "You can either get back to work or go to the office."). Step away and give them some time to respond. If the student complies, recognize that and acknowledge their cooperation. (e.g., "I'm glad that you made that choice.") If they continue to escalate, implement whatever the pre-planned consequence school emergency procedure is (i.e., clear the room or get other adults). Whatever the policy and procedure is at your school. But the biggest thing with signs of escalation is to stop talking. The more you talk, the more that behavior is going to escalate. Nobody has ever talked somebody out of a meltdown. Be careful not to just feed into the behavior or give in. Is there a contingency plan (e.g., Ok, sit in the chair for five seconds and then you can do it.)? Do not show disappointment or anger. Do not lecture or threaten. Try not to physically intervene if possible. Many students don't remember what they did so lecturing them after the fact is probably not going to help. It may even escalate their behavior again. Instead, really think about what do I need to do differently the next time?

Evaluate the Plan

Evaluate whether or not the challenging behavior is decreasing in intensity, duration, or frequency. Is the plan being implemented consistently? Is everybody doing it and how do we know that? Do we need to give it more time? Some behaviors get worse before they get better. Some children have been doing behaviors for a certain amount of time and they are going to "up the ante" to see if you're going to hold out or not. Do we need to modify any part of the plan? Do we need to change some of the preventative strategies; those antecedents? Is there a different skill we need to teach? Is there a different consequence we need to put in place? Do we need to change the hypothesis? Maybe we thought that they were doing it to get a break. But when we put the break in place, the behavior keeps happening. Maybe they are trying to tell us that they need more reinforcement when they're in the classroom or they need the work to be modified.  Maybe we need to change that hypothesis.

Summary

All behavior serves a purpose. Behind every behavior is a positive need. It's important to look at behaviors objectively with our ABC data.  We have to constantly re-evaluate the plan. Do we have the right hypothesis? Are we putting the right intervention in place? We must update that plan if behavior does not change. We have to all be consistent and think about what is a target behavior?  What is the objective information as ABCs? What's the hypothesis? And remember, that hypothesis is going to guide the intervention plan. Then, that intervention plan will consist of preventative strategies, teaching different skills, and changing consequences.  We want to do positive reinforcement and make sure that it's changing the target behavior.