Saturday, January 22, 2011

Strategies for managing challenging behaviors

In my last post I shared some tips on how to get your child to take their vitamins. At the end of that post, I alluded to some strategies for managing behaviors by setting up a supportive structure and reward system.  I know it wasn’t very nice of me to leave you hanging like that, but I am now ready to extend a hand and get you off the cliff you’re hanging from. Without further adieu, let’s discuss some great ways to manage challenging behaviors.    
Rules
If we didn’t have rules in our house, I think I would explode from all of the chaos. Most kids on the autism spectrum respond in some way to rules and boundaries. In fact, this can be an easy way to manage your household when you have a child who is strictly rule-bound. Setting clear rules of expected behavior is a first line of defense in keeping everyone in your household sane. Coming up with a list of rules to be enforced will differ depending on the age and development of the child. For the younger set, you might choose to designate one rule at a time, or make up a few rules with pictures that express the idea of the rule. For older children, you can involve them much more in the process. They can help make the list by writing rules on a piece of paper, decorating the paper with artwork, or even collaborating on ideas for what rules should be created.
When my kids were younger, I listed rules in very simple terms (3 words or less) and then added pictures for the benefit of my younger son who couldn’t read the words. For example, there was one that said, “Quiet voice” colored in green to indicate this was a desired behavior. Next to the words I placed a clip art picture of a smiley face with his index finger up to his lips as if he was saying, “Shhhh.” Then, below the green desired behavior I listed the undesired behavior, “No yelling” in red letters with a clip art picture of an angry face that appeared to be yelling. I went through this process for several behaviors that we were having problems with in our house. Another rule we had was, “Calm body” with its counterpart, “No hitting.” Now that my boys are a little bit older, we try to involve them more in the rule-making process. My husband and I always choose the first rule, which is whatever we deem as the most critical area of concern at the time. Then, each boy gets to choose several rules out of a list so that they feel like they have some control over their own daily destiny. Although some of the basic rules of the house apply to both boys, additional rules are customized for each child since they have different issues.  
Rules can be literally anything you need to work on with your child, from simple things like eating at least one bite of dinner, to more complex behavioral problems specific to your child. What I have learned about kids on the spectrum is that you can tell them what NOT to do all day long, but they won’t know how to comply because you haven’t told them what they CAN do. By focusing the rules on the positive angle of what behaviors you expect, it’s easier for them to make the connection. Keep in mind, rules are never stagnant. They should change and grow with your children. Issues will come and go, and so should the rules. Be prepared to teach the rules consistently, but then also be willing to change them if they no longer fit the situation.  
Here’s a cool little tip, especially for kids who are younger. I actually learned this trick from an Occupational Therapist who always got my boys to do exactly what she wanted, even when they didn’t want to cooperate. In the past, when my boys didn’t want to comply with the rules, I would shift the blame and make it the rules’ fault. For example, “I know you don’t want to follow the rule, honey. It’s not fun for you and you don’t like it, but I’m just reading what the rule says. The rules are kind of pesky sometimes, aren’t they? You know that if something is on the rule list, we have to do it. I could really use some help. How about you come over here and help me read the rule so we know what we have to do.” During this little conversation I’d be making faces and gestures all to back up the fact that the rules were to blame. This form of trickery did well until a certain age and then was no longer very effective.
Picture Schedules
If rules aren’t your bag, or you have a younger child who doesn’t respond well to rules, then you might try a picture schedule. This is a great method for kids of all ages who need a little help moving through their day. Having a picture schedule saved my sanity when we were having significant issues with my youngest son. At the time, he was nonverbal and had violent tendencies. He always seemed to be in fight or flight mode and often couldn’t handle even the simplest transition without a major tantrum. Once I learned how to implement a picture schedule, things calmed down quite a bit. I had one picture board for the house, one for the car, and one for his preschool classroom. Our most difficult time of day by far was the morning. I gave him the picture board when he first woke up and he would carry it around with him as he did all of the items in his morning routine. He liked to have the board next to him so that he could reference it as often as he needed. It sat on the table while he ate his breakfast and was on the counter when he was in the bathroom. It provided comfort and routine, which helped him become less resistant to our daily tasks.
Most pediatric therapists I know use picture boards to help their patients work productively through a session and accomplish specific goals. Typical ones I’ve seen in a therapeutic setting are constructed with a manila folder or a binder that has a Velcro strip placed vertically on the surface. Then, they attach small laminated pictures or clip art to the Velcro in the order that the activities are planned to happen. By talking about the items on the scheduled list and placing them on the board together, or even having the child select specific activities, there is much less resistance to following the schedule. If you encounter resistance, you can also use the shifting blame routine and go on about “that pesky picture board” and the various items on your list.    
At my house, I used a small magnetic white board. I was fortunate to have our OT print off a whole bunch of clip art pictures from their software system, Boardmaker. I laminated the pictures and then placed a small square of adhesive magnet tape on the back of each picture. If I needed additional pictures, I could draw my own, download clip art images off the internet, or take a photograph. I chose to use a magnetic white board because it afforded me more flexibility than using a Velcro system. My son was so sensitive to changes that I needed to have the option of drawing a picture on the white board with a dry erase marker to take care of things I might not have pictures for, or for last-minute changes in our plans. I limited the schedule to no more than 5 items at one time so that it wouldn’t become overwhelming. After those items were complete, we could move on to the next 5. The dry erase board was perfect in situations where I realized I’d forgotten to place an item on our list. It was not uncommon for me to scribble a picture on the board while in the car at a stop light after I remembered that I needed to go to the bank before going to the grocery store. My son did fairly well with the change as long as he got to hold the board as we talked about the change and then went over the new order of events several times.
Social Stories
Social stories can work very well for children who have language and can read. This was a technique I used with my older son, particularly when he was having problems in school with negative behaviors. Carol Gray is a pioneer in this area and she has several books available for purchase or to borrow from your local library. In addition, you can get social story templates and great ideas by simply doing a Google search. If your child likes reading stories, chances are they will really enjoy a story that is about them or things they do.
I have only purchased pre-made social stories from one company, Natural Learning Concepts. They have great stories available, and some have simple words that are easier for younger children to understand, and others have a more conversational writing style that appeals to older children and teenagers. We have about a dozen of their social stories at my house.
If you have a more complex issue, or a child who really loves doing art projects, then make your own stories. Involve your child whenever possible. After all, the story will be about them! Download a template off the internet or write your own. Have your child draw the pictures or write the words. And, if your child is able to collaborate on the problem with you, they can even help you create content for their story.
As with rules, take a positive approach when writing a social story. Instead of telling them what not to do, tell them what they can do to overcome the problem or task. My son was having trouble with copying what other kids were saying in the classroom. His echolalia was creating a lot of discontent among his peers and was affecting his relationships with the kids in his class. So, we created a social story to keep in his daily folder that he could reference at specific times of day when this was likely to be a problem, or whenever this became an issue. There was a picture of him on the cover of the “book” and he signed his name below it. I typed out the words of the story and he illustrated every page. Here are a couple of sentences excerpted from his story: “Sometimes I see kids talking together. They are having fun. I would like to join them. This is what I can do. First, I walk over to them, and I make sure to give them space.” I went on from there to discuss 5 ways that he could talk appropriately with the children in his class. With the teacher’s support in implementing the social story in the classroom, his negative behaviors subsided drastically in about 2 weeks and had completely resolved in about 1 month.   
Reward Systems
Reward systems can look very different, but essentially they are all the same: do what you are asked to do, and receive a reward when you do it. This is at the heart of Applied Behavior Analysis (ABA) and token economy systems. We have never used ABA with either of my children, but we have used a token economy reward system very successfully at our house. A reward system is best utilized positively. Rewards also work well to support the use of rules, picture schedules, and social stories. If the child follows the rule/picture board schedule/social story, they receive the reward. There are many ways to be creative with a reward system, and it’s only limited by your imagination. Getting your children’s involvement in creating the system is also a great way to get their buy-in. There are lots of free reward charts to be found online, and some of them even have popular cartoon characters as a visual incentive.
At our house, we set up a token economy system with treasure boxes and treasure coins. I’ve seen this done with marbles, M&M’s, stickers, tickets, or any number of other tokens. I purchased a small wooden box for each of my boys at the craft store. I had them help me pick out paint colors and stencils, which we then used to decorate their treasure boxes. I bought some party supply “pirate’s treasure” coins to serve as our tokens for their special treasure boxes. We used the tokens to provide a tangible way to support our rule system. Follow the rules and you can earn coins! I even made a list of age-appropriate chores they could do to earn additional coins, like help with laundry, pull weeds, etc. Then, we had a reward chart with pictures to show what they could get when they earned a certain amount of coins. Our chart was set up in increments of 5. For 5 coins you could earn 10 minutes of bubble time or a piece of candy. At 10 coins, you could watch your favorite show or play 30 minutes of your favorite video game. It went on from there up to 25 coins, which earned them a special outing of their choosing, like going to play miniature golf with dad.
When first implementing this program, it is important to watch for all possible opportunities to reward good behavior. This positive reinforcement, and the subsequent earning of goodies, will help them learn the system and gain their compliance. After a week or two, you’ll find that you have to work less to get your child to do what you ask. They will begin to understand their actions can earn them various enjoyable choices. And, if you’re interested in a lesson, it’s a great opportunity to add in math concepts. The reward system will need to change as often as necessary. If your child’s favorite thing changes from popping bubbles to riding their bike, then change the chart. As kids get older and tastes are more defined (Legos, Mario Brothers on the Wii, etc.), your tokens can carry more persuasive weight. As they get older and the reward system is fully integrated, you can even use tokens for negative reinforcement as needed. I’ve taken away coins for extreme negative behavior or blatant disregard of something important (like safety). There have been times I’ve issued IOU’s, meaning they had to earn more coins with positive behavior to get themselves out of the hole and back on their way to earning a reward. This has been very effective with my children.
Final Thoughts
All of the systems for helping to managing behavior will have much greater success when the following criteria are met:
1.       Get your child involved whenever possible – it helps them feel ownership with the system.
2.       Keep things positive – show them what they can do rather than always being negative.
3.       Be consistent – this eliminates confusion and helps your system(s) to work as intended.
As you work to create and implement a system that helps your child manage their day and behaviors, I hope you find that it brings a new sense of peace to your household. I know it did in mine! And, if all else fails, I say brew another cup of coffee and take a mommy time out behind a locked bathroom door.
Good luck!

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