The understanding and manangement of behaviour problems
Ben Sacks
Abstract - Behaviour therapy is a system of objectively describing particular behaviours and attempting to change them with the use of environmental factors such as reinforcers and cues in order to decrease destructive behaviours and increase and develop useful skills in order to improve the quality of life for those concerned. This article reviews strategies for the successful management of behaviour problems.
Keywords - Down Syndrome, Behaviour, Behaviour Management, Therapy
DefinitionBehaviour therapy is a system of objectively describing particular behaviours and attempting to change them with the use of environmental factors such as reinforcers and cues in order to decrease destructive behaviours and increase and develop useful skills in order to improve the quality of life for those concerned.
It is a person's behaviour, beneficial or unacceptable, that is the single most important factor which determines the way in which they are regarded, how their personal relationships develop, how they are helped or rejected, where they live and ultimately, how happy they are and how good their quality of life becomes.
Helping unacceptable behaviours to diminish or disappear and beneficial behaviours to develop and expand is something which concerns everyone and the techniques and approaches which enable us to achieve these ends need to be understood by all those in a caring relationship with others.
There are several reports in the literature dealing with behaviour, temperament and psychiatric problems in people with Down syndrome. Interpreting these data presents considerable difficulties because of the different systems of classification, types of measurement and definitions used.
An important issue in the consideration of human behaviour is that what appears to be identical behaviour may have different types of causal mechanisms; it is known for example that aggressive behaviours may have widely different mechanisms including many different environmental factors as well as biochemical, genetic and other variables. Attempts to ‘force’ behaviour in to causal systems are often based on guess-work and frequently lead to misunderstanding these behaviours. In addition, many behaviours are ill-understood and better dealt with on a pragmatic and / or experimental basis.
One of the advantages of the behaviour therapy approach is that it does not commit itself to causal mechanisms in advance and always keeps open the option that particular behaviours may be changed even without having a full understanding of all their mechanisms. Such an approach also means that some understanding of the behaviours involved may be obtained as a result of the behavioural procedure itself.
Approaches to changing human behaviour are very varied but it is the appropriate use of behaviour therapy that has not only produced the most dramatic effects but has also improved relationships between the various carers involved.
While most of the principles of behaviour modification seem obvious and sensible, some are not, and the practical problems of actually carrying out behaviour programmes may be the most difficult problem of all since this necessitates the co-operation, communication, trust and mutual support of everyone involved.
It is, therefore, essential that the formal and systematic approach and understanding of the basic principles of behaviour therapy be established in order to carry out an effective behaviour modification programme.
‘Structural’ issuesIn addition to embarking on a behaviour modification programme it is important to ensure that other factors which may affect behaviour are identified and dealt with as effectively as possible. Some of the areas which need to be examined are as follows:-
1. Physical healthMany physical disorders can be responsible for perpetuating unacceptable behaviour and / or making them more difficult to change.
Some of the more common are:
a) chronic pain from any cause; for example, infection of the ears, urine, teeth and chest;
b) disorders affecting vision;
c) disorders affecting hearing;
d) epilepsy;
e) disorders of thyroid function.
2. Communication problemsAny such disorders, especially those in which the ability to express oneself is impaired, are frequently associated with behaviour problems.
3. Psychiatric disordersAny psychiatric disorder can be associated with difficult behaviours and may also interfere with the learning of new skills. Such disorders need to be properly diagnosed and effectively treated.
4. Personal relationshipsHostility, anger and lack of support from carers, friends and relatives may have profound effects on behaviour and unless these factors are dealt with, behaviour modification programmes often fail. The departure, illness or death of important carers may also have serious effects on behaviour as well as feelings.
5. FrustrationAny factors causing frustration, especially when associated with a lack of help in dealing with them will also interfere with behaviour modification programmes and such problems need to be dealt with as well as possible.
Problem behaviours may remain after the above factors have been addressed - mainly because of the following three factors:
1. HabituationA behaviour which has been carried out for any length of time may become a habit. Even if the original cause has been removed it may persist. Such habits need to be treated with behaviour modification techniques as separate problems.
2. Inappropriate reinforcementThe ‘encouragement’ of inappropriate behaviours is probably the most common reason why these behaviours persist. This issue will be discussed in greater detail below.
3. Other environmental factorsIf a person is unhappy, disturbed, afraid or bored it becomes much more difficult to deal with unacceptable behaviours, or indeed, to teach new behaviour. Such factors need examination and correction as far as possible.
The vast majority of behavioural difficulties are entirely or predominantly psychological in the sense that they are learned behaviours and, therefore, amenable to behavioural approaches.
Of the several different approaches under the general heading of behaviour modification the most important strategies are those based under the rubric of Operant Conditioning. The principles underlying this are simple in theory, but, as always, more difficult to carry out in practice.
We live in a culture where causation is seen as something which happens first and produces a result later - for example a pinprick on the finger causes the hand to be drawn away. However, this logic does not normally apply to learned behaviours where the causal relationships are, at first sight, not so obvious and easy to understand; for example if asked why a person picks up a telephone most people would say that it is because the telephone rang. However, if there was no one to speak to at the other end, we would soon tire of picking up the telephone when it rang. Clearly, it is because of the fact that something happens after the behaviour (someone talking) that makes us continue to carry out this particular behaviour. The implication of this little example is, therefore, that the most important cause in this type of learned behaviour i.e. (picking up the telephone) is the consequence, without which there is no point in picking up the telephone.
This is the basic principle of Operant Conditioning i.e. it is the consequence, the result, the reward or reinforcement of the behaviour that is the crucial element. This concept is illustrated as follows in Figure 1:
The link between the behaviour and the immediate consequence is shown as a thicker line because it is the major determinant of this behaviour and it develops in to this major factor through a process of learning, which may take a shorter or longer period of time.
This link is a conditioned reflex which can be made stronger, weaker or broken altogether.
The importance of this principle is that by appropriate use of reinforcers the preceding behaviour may be weakened or strengthened.
It is important to understand that reinforcers are defined by the effect they have on the preceding behaviour and not on whether we think they should be reinforcing or not.
For example if a mother said "the more I shout at him the more he does it" she is illustrating that shouting at her child is a reinforcer because it is increasing the preceding behaviour although she thinks that because shouting is unpleasant, it should stop this behaviour.
By far the commonest cause of difficult behaviours is reinforcing such behaviour - often without realising that this is what has been done.
In order to effectively take advantage of the behavioural approach the following procedure should be followed:-
1. Describe the target behaviour to be changed (increased or decreased).
2. It is important not to jump to conclusions about the cause of a behaviour because it is difficult to be sure about this and often different people will have different interpretations of the target behaviour. This results in difficulties when communicating about a behaviour and how to deal with it. For example, if a child is aggressive some people might think that he is ‘naughty’, some may think he is afraid, some that he is frustrated and others that he is enjoying this behaviour. Interpreting behaviours may produce confusion and even conflict in the early stages of the behaviour programme and should be avoided.
3. Once the behaviour is described it is then useful to observe it for a short time. This is in order to obtain some idea of its frequency and intensity.The importance of such measurements is that without such a baseline it will become difficult to follow up changes in behaviour - whether it is increasing or decreasing in frequency or whether it is not changing at all.
It is of great importance to have some system of measurement since the changes that take place after the behaviour programme has started gives information about the effect of this intervention and whether it should be changed in any way. Measurement is often neglected because it is thought to be too difficult to do. However, even fairly crude measurement, as long as it is recorded, is usually adequate.
During the baseline period it is also important to observe the occurrences which happen before and after the target programme. Such observations may offer the opportunity to make an informed guess about what the reinforcers as well as the cues might be - the so called A B C approach:
A = Antecedents,
B = Behaviour,
C = Consequences.
One should then be able to produce a programme in which the reinforcer could be manipulated to either increase or decrease the target behaviour. If it is desired to increase the target behaviour then the reinforcer should be applied immediately after this behaviour. If it is desired to eliminate this behaviour then the reinforcer should not be given at all.
The apparent cue may also give information about which factors tend to initiate or precipitate the behaviour and therefore give warnings about the behaviour starting. It may also be possible to manipulate such cues to help reduce the behaviour. It must be remembered that the ‘real’ cause of the behaviour is the reinforcer. Once this perpetuating stage has been reached a written programme should be produced. This has a basically straightforward structure (see Figure 2).
Everyone involved in the carrying out of the programme should have a copy of the programme and a system should be worked out to ensure that all the records can be graphed on a single piece of paper. A simple example of such a programme may be as shown in Figure 3.
In this particular case there seemed to be no stimulus during the baseline period. The child was sitting quietly when he got up and started to bang his head. While he was banging his head, his mother went up to him and put a cushion between his head and the wall and tried to distract him. It was decided in this case to try to ignore the head banging since it was thought it was being reinforced by mother’s attention. In this case the head banging got worse as is seen on the graph, but eventually it became less and less until it disappeared all together.
Interpretation of the dataIf the target behaviour that the programme is meant to eliminate increases in frequency during the early stages of the programme it is usually evidence of the fact that:
1. The programme is having some effect on the behaviour - this means that the target behaviour can be effected by environmental factors and is, therefore, likely to have a large learned component and
2. Such an increase could mean that the unacceptable target behaviour is increasing ‘in order to try harder to get the now absent reinforcer’.Both of the outcomes are encouraging and suggest that the programme has been structured on the right lines and should be continued.
Some principles of behaviour therapy.1. It is task orientated. The specific behaviour is analysed and the programme organised to change this particular behaviour.
2. Positive reinforcement is always part of the programme. This leads to positive attitudes and relationships and emphasises new good behaviours rather than concentrating over-much on negative behaviours.
3. Separating the sin from the sinner. It is the behaviour that is disapproved of and not the individual. Positive relationships are always emphasised, for example, "I love you but it is the behaviour that we all (you included) are trying to eliminate".
4. Measurement matters. Without measuring the change in frequency of the target behaviour it becomes extremely difficult to judge progress and therefore to know whether it is necessary to change the programme or not.
5. Co-operation. Everyone involved must co-operate with each other and must adhere to the programme. If it is decided to change the programme this must be done co-operatively. It must be re-written and copies given to everyone concerned.
6. Consistency. Everyone must carry out the programme in the same way. If only one person does not carry out the programme correctly it may cause confusion in the subject and conflict among the carers - this is called sabotage. A simple programme well carried out is much better than a clever complicated programme which is badly carried out.Behaviour modification does not interfere with any other kind of treatment and in most cases they reinforce each other i.e. they should both be used.
In order to change behaviour, programmes should be carried out more-or-less all the time and in all situations. They tend not to work very well if they are carried out only spasmodically - this is a common cause of failure of behaviour programmes.
Team workUnless all the people carrying out the programme communicate with each other regularly and discuss the programme, the way in which it is being carried out and any other problems that have emerged, the programme may not be effective. Programmes need to be regularly reviewed and changed as necessary otherwise they will not be carried out with any degree of conviction. Such communication is also beneficial for the carers since it creates opportunities for discussion of each others problems and it also creates opportunities for mutual support.
The proper use of behaviour modification can help to produce real and important changes in people as well as carers and, properly carried out, improves the quality of life of both.