Pediatric Client Behavior: How do I manage it?

Julia Caserta

When I started graduate school for speech-language pathology in 2014, I had a well-developed understanding that behavior management would be a large part of my work every day. My background is working as a para-educator for special needs students in the elementary school setting and supporting adults with severe to profound developmental disabilities in a group home setting. Both settings have granted me experience, understanding and compassion for people with behavioral challenges. In this work, I realized, the individuals I was supporting were using behavior for an essential purpose: for communication! This knowledge lit a fire in my mind, and when I entered graduate school I was determined to serve those clients who had limited means of verbal communication.

Fast forward three years, and I entered the work force as a speech-language pathologist with special training in Alternative and Augmentative communication (AAC). I was surprised to find that behavior management was rarely discussed in a formal way, even though it was an issue
that nearly everyone in my field was dealing with and one that was a frequent source of workplace stress.

If you are a teacher, speech therapist, occupational therapist, nurse, dentist, physician, or other related professional, you will come across clients in your work whose behavior poses an impediment to their progress. This might leave one feeling lost, or like a failure, and might lead to ‘giving up’ on helping with behavior, which in turn, affects treatment and progress for the client. This begs the question: what can we do to support clients with more intense behavioral challenges? As with many aspects of life, changing a well-established challenging behavior is a marathon, and not a race!

“When a flower doesn’t bloom, you fix the environment in which is grows, not the flower.”
– Alexander Den Heijer

How do we define ‘challenging behaviors?’

Any behavior that interferes with that person’s ability to learn, interact with others, or function in an activity of daily living. Behaviors are considered severely challenging when the behavior causes physical harm to the person exhibiting the behavior or to others around them; in other words, behaviors that put people in danger.

Behavior: The BIG Picture

Behavior is COMMUNICATION, especially for those with moderate to severe communication disorders. Behaviors have FUNCTIONS: what need is the behavior meeting? This can be broken down into: Obtain = tangible, sensory, attention, OR Avoid = tangible, sensory or attention. Clients, patients, or students may have learned through intentional or unintentional reinforcement that a certain ‘behavior’ gets them something they ‘need.’

The Escalation Cycle of Behavior

Escalation cycle (no date) Escalation Cycle – Tier 3 PBIS (PENT). Available at: https://www.pent.ca.gov/pbis/tier3/escalationcycle.aspx
(Accessed: 03 August 2023).

• You can see the escalation cycle of behavior; agitation rises over time following a trigger.
• Typically developing people often show signs that they are becoming agitated, which gives others around them time to adjust to reduce agitation.
•  Children with developmental disabilities, such as autism spectrum disorder, may not
  exhibit predictable signs of agitation or may have atypical signs of agitation, which leads to some challenging behaviors to seemingly ‘come out of nowhere,’ leaving communication partners confused.
• As agitation goes up, cognitive abilities (needed to process complex language) go down.

Important Note on Behavior

It is important to know how behavioral challenges develop over time:

• You can see the escalation cycle of behavior; agitation rises over time following a trigger.
• Typically developing people often show signs that they are becoming agitated, which gives others around them time to adjust to reduce agitation.
•  Children with developmental disabilities, such as autism spectrum disorder, may not
  exhibit predictable signs of agitation or may have atypical signs of agitation, which leads to some challenging behaviors to seemingly ‘come out of nowhere,’ leaving communication partners confused.
• As agitation goes up, cognitive abilities (needed to process complex language) go down.

Behavior Management Basics

At this point, you may be asking yourself: What can I do in the moment?
1. Observe the behavior and create a safe space (move people or things out of the way).
2. Acknowledge their feelings and communication.
3. Redirect the behavior away from the ‘trigger.’
4. Use visuals or low-tech communication boards and tools.
5. Talk to caregivers about pain, problems with sleep, nutrition, etc. to determine if there may an underlying physiological reason for the behavior.
6. Re-engage once the client is calm.
7. Work to build trust and communication; do not force the patient to do anything that will cause an increase in challenging behaviors.
8. Ask yourself: does this client have all of the information they need? Can I present this information in a way the client/patient/student can understand (e.g., visuals, social stories, video modeling, etc.)?
9. Utilize visuals: schedules, first-then schedules, and picture command cards.
10. Decrease verbal communication; use simplified language.
11. Offer concrete choices (e.g., “Do you want to sit or stand to take a break?”).
12. Tell the client what they can do in the affirmative and not the negative. For example: “You can sit down,” instead of “Stop running, no, stop that!” or use “Hands in your lap,” instead of “Don’t grab that!”

Perhaps you have recently had a tough behavioral episode with a patient, client or student, and you might be asking yourself: What can I do to prepare before the client or patient comes in next time?

1. Prevent triggers whenever possible.
2. Use visuals and low-tech communication boards.
3. Dim the lights and minimize distractions.
4. Use video modeling and social stories to prepare the person prior to the appointment.
5. Talk directly to the client/patient/student in a kind and calm way (do not talk to caregivers about the client/patient/student without them being included in the conversation).
6. Involve the client/patient/student in decision making as much as possible.
7. Praise and reward the client/patient/student‘s effort.
8. Be consistent across the person’s entire team.
9. Work on replacing challenging behaviors over time using the FERB framework.

I’ve never heard of FERB, what is that?

• FERB stands for Functionally Equivalent Replacement Behavior. The goal of FERB is to answer the question, how can clients/patients/students get what they need without engaging in challenging behaviors?
• For the replacement behavior to be in line with FERB, the replacement behavior MUST serve the same purpose as the original behavior.
• Examples:
    o Hitting in order to escape something the person sees as scary = teach the person to ask for a break or say “all done” before hitting.
    o Chewing on their shirt as a sensory need = teach the person to use an appropriate chewy instead.
• Replacement behaviors must be taught and used consistently to work; talk to your client’s caregivers and team members to make a plan of action!
• If the FERB is appropriate and used consistently with the person, challenging behaviors will be replaced by the FERB over time.

Tools for Everyday Use:

• Video Modeling: make a video of the situation that the person has trouble with. The video needs to be from the person’s point of view, and it needs to include all the steps they will be required to complete. Here is a link to an example from COR Behavioral on YouTube:
  https://www.youtube.com/watch?v=MvaZ4cQ33tI
• Social Stories: developed originally by Carol Gray, social stories are written from the client’s point of view and tackle a specific scenario. Find more info here:
  https://carolgraysocialstories.com
• Visual Supports and Visual Schedules: use visual maker software or take pictures to show what the person will do (first, then, and last) for a given scenario.
• Low-Tech Communication Boards: if the client has limited means of communication, a simple communication board can facilitate the communication of their needs, decision making and participation. Find examples of low-tech medical boards here:
  https://www.med.unc.edu/healthsciences/sphs/wpcontent/uploads/sites/600/2020/04/COVID-AAC-Final-Version.pdf