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Typical Uses for Behavior Management in Long-Term Care

By: Russ Moulton, Psychologist

Challenging behaviors
- disturbing vocalizations (screaming)
Physical aggression - hit, kick, throw things
Irritating behaviors - whining, constant attentional needs, delusional statements

Typical Maintaining Functions of Challenging Behavior
  • Attention gain
  • Escape from demands
  • Automatic (Positive/Negative) fear reactions, sense of loss, rejection, confusion, boredom, lack of control, power over others, physical pain/illness

Behavior Management is only effective treatment of choice if the behavior of concern is mediated (connected) with environmental variables.

Example. A person screams frequently, loudly, disrupts other residents - but does not scream during family visits, when in church, or while on a community outing. You begin to predict when, and under what conditions, the behavior will occur or not occur.

Example. A resident pushes the Nurses call light continually and screams until someone enters their room. The person has no discernible problems. Shortly after you leave the behavior reoccurs.

Example. A resident frequently falls from her wheelchair, which has resulted in numerous injuries. A review of the files indicates that the falls have occurred within a 30’ radius of the Nurse’s Station. She has never fallen from her chair in her room, while interacting with staff, or while outside the facility with staff.

Example. A resident frantically talks to her parents (long time deceased) who she believes are in the pop machine in the break room. The behavior only occurs in their presence of staff, never when she is alone and not when residents and staff are engaging her in conversation.

Example. An elderly female resident was refusing to leave her room. She was always immaculately dressed and groomed, but would only venture out of her room if staff was persistent. She was losing weight and everyone was concerned for her welfare. When asked why she was afraid to leave her room, she stated that she starts to leave every morning, but the Alzheimer’s patients are gathered outside of her door (medications and breakfast) and she is afraid that they may become agitated if they see her. She decides to stay in her room.

The value of Shaping:

A male resident began urinating in a trash can in the hallway near the bathroom door. Scolding, escorting him to the bathroom, and putting him on a toileting schedule only seemed to make matters worse. “Depends” was the next logical step. Instead, the trash can was moved just outside the bathroom door. He continued to urinate in it and it was then wedged in the door (only during the typical times that he used it). The trash can was placed inside the bathroom and he continued to use it. The toilet urinal was painted the same as the trash can and the trash can was removed. He continued to urinate in the appropriate place. All of the trash cans were replaced.

A female resident would routinely go in to other resident’s rooms and take whatever items that she could wear in terms of jewelry. Needless to say, the other residents were extremely upset and wanted the administrator to get rid of her. A plan was devised to turn an area into a foraging room for her. Everyone pitched in by bringing/buying old jewelry into this room and hiding it in the dresser. She was directed to this area whenever she was caught in someone’s room and after awhile, just began going to the designated area to find stuff.

Staff in Human Services fields continually attempted to manage the affairs of the people they serve, whether it is to solve a problem, help with a dispute, perform a skill or to take a medication. Staff frequently find themselves in the role of managing behavior. With most residents, this is a rather casual process. It may involve a promised cup of coffee for taking a bath or a pat on the back for using that new walker for the first time.

All goes well until you are confronted with a person who doesn’t budge with coaxing or who you run out of things to bribe them with in order to take those medications. These people seem to have a problem and we fairly quickly label them as such. They frequently are called stubborn, bullheaded, demented, or other such labels that set them apart from the more responsive people.

Therefore, it is of no great surprise that staff indicate that they have tried behavior management and it has failed. The problem quickly becomes a medical issue of sedatives and mood stabilizers to really solve the problem.

Then again, what is Behavior Management? Is it the coaxing, bargaining, bribery, or demanding concepts that we thought? The answer is no.

For one thing, it is systematic with an analytical flavor. Certain questions have to be asked and answered. When, where, and under what conditions does the behavior of concern occur. Is there a time that you can predict that it won’t occur? The conditions in conjunction with a behavioral concern are called Antecedents. Antecedents can be recent or remote, but set the stage for the behavior to occur. Antecedents often involve the situations at the time and how staff relay their expectations (e.g., time to bathe).

I just worked with an elderly lady who was referred because she would not eat. Coaxing and promising things for eating had little impact. She would gag, choke, scream, and otherwise show her displeasure for the process. She did indicate that she would eat if taken to her favorite local diner. Here she ate quite well without choking, screaming, or doing anything else that she was doing at the facility. At least she was eating one meal per day. The facility was concerned because they did not always have staff available to take her and she had very limited funds.

What would you make of her eating disorder? What, if anything, is maintaining this behavior? How would you go about managing her behavior?

Additional Thoughts
: Determine an approach to take for people accessing the information on a website.

One way that would seem to be effective is providing case scenarios (e.g., the antecedent, behavior, consequence) and then asking if this is something the person has encountered... asking what was done to address or correct the problem... asking what the results were... and then providing the additional information regarding alternative techniques that may be tried.

This approach would not only get the individual into the mode of assessing the ABCs of the behavior, but in addition, hopefully would allow them to gain a better understanding of what maintains the behavior (functional analysis), while learning the techniques of behavior management.

The appropriate techniques would be offered as other possible solutions to the hypotheses gathered in regard to behavior function. Basically, it incorporates a ‘no-fault’-based model so that the person requesting information would not feel as if they had done something wrong in the way they have handled the situation thus far (even though that may be the case - wouldn’t want them to feel that way).

Or - They provide the case example; we provide the possible solutions

Or - Listing of numerous techniques and under what conditions to use them

Or - Success stories of using creativity, techniques, staff involvement

Or - A general prevention program for staff, how to maintain control, how to assess, how to analyze