Panel Discussion  – Beyond the Behaviour : Strategies for understanding and managing challenging behaviors 

Hi All,

The below post is related to a topic which was part of the Conference / Workshop organized by Vasantham. Below are the details of the session:

Conference – Workshop cum conference on Best Practices in the rehabilitation of individuals with special needs
Date – 17th March 2023   16:00
Mode of Presentation – Offline

Venue – Sengai Meenakshi Mahal, Mogappair, Chennai – 37
Topic – Panel Discussion  – Beyond the Behaviour : Strategies for understanding and managing challenging behaviors 

Speaker –  Mr.Shiva Prakash Srinivasan – Psychiatrist, Sri Vikas Centre of Mental Health 

Below are the points shared in the presentation:

Behavior are habits, to be more precise it is a verb, i.e. an action. Crying, biting, hitting, shouting, banging, doing, etc. all words ending with  “ing” are behaviours. Behaviour is something everybody has, what makes it challenging or not is the application or usage of the behaviour in an acceptable manner. Me cleaning a table at my home is acceptable behavior, me cleaning a table at a doctors office is not an acceptable behaviour. 

A Behavior is considered as challenging if any of the below conditions are met:

1) Any behavior demonstrated beyond an acceptable limit

2) Any behavior that does not match with the surrounding / environment / situation

3) As a result of the above two, it is impacting the child from performing regular tasks like reading, writing, listening, etc..

We normally think challenging behavior as something like hitting, running, biting etc, but we are not thinking whether that response is correct as per that situation or not. For example, if you are taking your kid to the park, you should not expect that your child should be holding your hand all the time, the kid is expected to run around the park. But when crossing the road, holding your hands is acceptable, but holding your hands at the park is not an acceptable behavior. The same action depending on the situation becomes acceptable / unacceptable behavior. So a challenging behavior is something that is in excess of what is expected or does not match the present situation or does any harm/negative impact to the child.

In a school environment, the setup by itself is very systematic, the child will get adjusted to the routine and the system sooner or later. But the issue is that any change in the system makes it hard for the student to accept or move forward. For example, in a classroom we have a child with special needs, he observed that his teacher who was wearing glasses all the time removed her glasses and placed them on the table on one particular day, which was new to the child as he has always seen her wearing the glasses and not without. He was unable to sit in his chair, he was restless, his brain was unable to process the change that had happened, he calmed down only after the teacher wore her glasses again. Without making this observation, we would have not known what caused the child to lose the sitting tolerance all of a sudden, the number of times you might have asked him/threatened him to sit would not have resulted in any positive outcome. It would have only made things worse. We have to make a list of unwanted behaviours that the child is exhibiting and make observations behind each of them, and look at strategies to resolve them one by one. How we respond to the behavior matters, the more we say “don’t do it”, the more occurrences of that behaviour is guaranteed. 

In case of aggressive behaviours, we first need to look into how, what, when, where of it. If the behavior is happening in a particular situation all the time, we should look at the possibility of changing the situation to avoid that behaviour. If the behaviour is caused by a parents response, we have to see if the parents response to behaviour can be changed. We cannot ask the child to change the behaviour simply. For example, all the people who are driving vehicles, you would most likely stop at a signal if there is a traffic police standing next to it and not otherwise. As an adult we ourselves are not listening to the acceptable behavior, hence we cannot expect the child to change just because we have told them to. 

As a psychiatrist, I do not have medicine to give to an adult that will make him stop at the traffic signal every time. But certain behaviours can be a symptom of a disease. Like obsession, anxiety, panic, repetitive / circulation of thoughts, unable to sit at one place, etc .. in those situations, medications can be given to reduce the panic/anxiety. Similarly for impulsiveness, there are medications that can help. For scenarios we could not figure out what is the cause, there are medications that will make the child numb/sit idle.

There are plenty of options when it comes to drugs, before choosing the type of drug, it is essential to make an observation of that behavior, look at ways to change it, how we respond to it, as a last resort if there is an underlying disease, we recommend drugs.

Irrespective of whether an adult or child is under medication or not, 6 to 8 hours of sleep is essential for parents and children, it is a problem if the sleep time is either more or less. For example, assume that in order to reduce the extreme hyperactivity of a child I have given a drug which will calm down the child, but it may result in making the child sleepy. Hence if you provide this medication and send the child to school, you will get a complaint that the child is now sleeping in the classroom. This medication was intended to make the child sleep at night. If we do not use the medication properly we will end up replacing one challenging behavior with another challenging behavior. Our focus is to make the child learn, if the treatment which is given to the child is hampering the learning process we should revisit the treatment and make modifications to it. 

Q – How to give more responsibilities to a child and How to stop the habit of children constantly commenting or narrating the work they are doing ?

A – As a parent, if you think that you should be doing all the work for the child and asking your child to perform any task is like torturing him, like putting the plate in the sink, dropping the clothes in the laundry basket, etc.. Only if you give responsibility, one will learn to become responsible. It has to be age appropriate responsibilities. As a parent you have to be brave and courageous when the child is learning to become responsible, it is not going to be a cake walk, there will be errors, mistakes, blunders, etc. all are going to help them become responsible, if we do not interrupt the process by helping them in between.

In general we all have an internal dialogue, where we keep talking with ourselves as to what is our next task, how are we going to complete it, what we need to complete it, do we have all the required items to complete the task etc…this is very common, for few children they do not have that filtering capability, as a result they do an explicit verbal commentary of their thought process, this is not a disease it is a different way of people doing things. Such differences are not limited to children with special needs, you can see it with neurotypical children as well. Unless the different way of doing things is causing harm to others it shall be ignored, else we need to address it. You can provide a reward to the child each time he does a task without running commentary or narration. 

For example, next time when you are struck at a traffic signal and you look around what other people do, you would see a percentage of people talking to them (without phone or bluetooth) during that waiting period, it does not mean they are having a disorder or severely disabled or developmentally delayed. Until that behavior causes an issue it can be ignored.

It is extremely important that we acknowledge, reward and give importance when the child does what is expected of him, We are spending too much energy and focus on the child when the child does not perform things in an expected manner, but many a times we ignore or do not acknowledge when they do it in a right manner.

For example, assume that your child does not pick up the plate after eating to drop it in the sink, after your constant reminders, warnings, threats only he does it. Now you want him to do this by himself. So whenever he does drop a plate on the kitchen sink, you could say:

1) He did a very good Job

2) I liked it when you went to the kitchen sink  by yourself to drop the plate

3) You can clap

4) You can say Thank you

5) Give stars or points

6) Give a hug, thumbs up, high five

7) Appreciate him that he is being responsible

8) When the dad comes back after work, you can tell his dad that today our son has kept the plate by himself in the kitchen sink.

Always provide opportunity to the child to become responsible.

Q – What happens when the child becomes over-dependent on the reward to perform any task ? How to handle it ?

A – When someone does a very hard work they are entitled for a reward, there is nothing wrong with it. However, if we are going to adapt reward mechanisms for day to day tasks, then the reward that we are going to choose has to be appropriate. You need to re-define the criteria for the reward as the child progresses. Assume that on day one the child has taken one cloth and dropped it in the laundry bag, so you gave him a reward. But after one week, you will only give the reward if the child drops a minimum of 3 pieces of cloth on to the laundry bag.

Today morning when I brushed my teeth, no one appreciated me or motivated me or gave me the reward. But if i assist my kids when they brush their teeth, my parents may appreciate me for it. There is nothing wrong in giving a reward , but it will always have to be phased out. If you work for an entire month, you will get a month’s salary, and if you work for half a month you will get half salary, similarly reward should be based on the task that is performed.

Q – There are circumstances where children do certain activities that either harm others or self harming. Is that an indication for the parent to approach a psychiatrist ?

A – After consulting a psychologist only one should approach a psychiatrist. Assume that a child is pinching others or himself, we do not have a medicine that will stop the fingers from pinching. We need to capture as much data as possible about that behavior to get an understanding of that behavior, only then the treatment will be decided. There is no specific medication for stopping a child from performing self injurious behavior. We have medication to reduce the impulsiveness, anxiety, anger etc. treatment will be for the cause and not for the symptom. If you have a fever, we will not stop only with paracetamol, we will also provide antibiotics along with it to fight the cause. So do not focus on the paracetamol, focus on the antibiotic. 

From a psychologist perspective , find the situation in which such behavior comes, try to avoid exposing children to such situations. Second is to use protective gears that will minimize the damage caused due to self behavior, like if the child begins to bang their head against wall, you can make them wear a head hear or helmet, to avoid harm to the body, if a child is using their hands to harm, you can use physical restraint by holding their hands to prevent any harm. 

Try to isolate the child, so that he does not cause harm to other children or others around. We know a few children who gets very upset and scared when they hear a crackers bursting sound, so when we anticipate such a scenario we put them songs or music with ear phones/noise cancelling headphones to mitigate the impact caused to them. If we observe and understand the child, we can find out the what, when and why of that behavior.

Q – As a caretaker and a parent how to handle the child with severe behavior issues, there is an increased amount of stress and burnout that is faced by parents, how to overcome or face it ?

A – How your child is going to school for 8 hours a day and your spouse going to work for 8 hours a day, you should have your own life as well. Only by taking care of themselves the burden on the caretakers can come down. There is no shame or nothing wrong about taking help from others. May be others may not be able to perform the task or duties like how you would have done, but they would still do their best to accomplish the task given to them. Only if you give responsibilities to others, they will learn from it. Next important thing is exercise, you would have a hectic schedule from morning to night, running from one therapy center to another, etc.. but it is very important that you do exercise every day.  People say that i walk all day inside my house, and treat that as an exercise for the body, is totally wrong. Unless you live in a palace that has 40 bedrooms, walking inside your house cannot be considered as an exercise. You need to do a 30 to 45 minute workout every day that should take your breath away and cause pain to any of your large muscle groups. Only then it could be considered as an exercise, what you do to get that result is up to you. Unless there is self care, you cannot care for anybody else. 

Q – Fixation on doing a task in a particular way, or asking the same questions repeatedly inspite of giving answers many times. How to handle it

A – Whenever a child does a task in a different way we are going to reward / appreciate him. By keep saying “Don’t do it” million times, is not going to stop them. Occasionally when the child does not do that behaviour, you take that as an opportunity to appreciate the child. Whatever behavior we give attention to , it will grow.  There are two types of attention i.e. Positive attention and negative attention. We give Positive attention when the child behaves in an expected manner, we appreciate them for doing it. We give negative attention when the child does not behave in an expected manner, that it keep saying don’t do it, stop it etc..

Choose your battles. Parenting the child is not a single day’s task. I got two kids myself, till date my mother is still parenting me by asking whether i have eaten, slept well, feeling alright etc..

Q – As you mentioned that a medication given to resolve one challenging behavior may give raise to another challenging behavior, instead of medication will ABA therapy be useful ? 

A – ABA will be helpful. But there is a misconception about the medication among many in general. All medications will not make the child sleep, cause weight gain, may have to be continued for life long, child will become addicted to the medication etc.. are misconceptions. These medications cannot be compared to the effects that a person gets from alcohol or nicotine or other drug substances which are guaranteed to cause addiction. For diabetes, I may have to take medication every day, which is not wrong. 

Even for starting ABA, to make the child co-operate and be in control, we still require medication in the initial stages. As time progresses, some behaviors can be handled by managing the antecedents. Next will be to desensitize the child gradually. Assume for a child who is scared of the cracker noise, you can give the noise cancellation headphones to handle the antecedent, later we work on desensitizing by listening to crackers sound that happens in a far away place, then to the sound that happens in the next street, then to our street, then to our own house, finally make the child to burst the cracker himself and stand far and listen to the noise. 

What you expect from the child , you have to be a role model for the child in those aspects. If we are not performing them, they will not perform it either. Also when it comes to dressing skills even if the child is one year old, always take them to a dressing room with closed doors for changing dress just like how an adult does. Female children to be handled by mother and male children to be handled by father has to be followed. 

Regards,

Saranya and Karthikeyan