Behavioral Approaches in Pediatric Occupational Therapy

Why Does Challenging Behavior Occur?

• Explored through both biological and ecological perspectives.

  • Biological Perspective: Factors such as neurotransmitters, which influence behavior.

  • Ecological Perspective: The environment's role in shaping behavior.

Neurotransmitters Impacting Behavior

• Dopamine:

  • Role: Associated with reward and motivation.

  • Impact: Low levels can impair motivation and attention.

  • Example: In Autism Spectrum Disorder (ASD), dopamine and serotonin imbalances contribute to repetitive behaviors and sensory sensitivities.

• Serotonin:

  • Role: Regulates mood and emotional stability.

  • Impact: Low serotonin linked to impulsivity and aggression, affecting behavior regulation in Cognitive Behavioral Therapy (CBT).

• Cortisol:

  • Role: The stress hormone, raised in anxiety or high-stress scenarios.

  • Application: Used in trauma-informed care where therapists aid in developing techniques to self-regulate cortisol levels.

• GABA (Gamma-Aminobutyric Acid):

  • Role: An inhibitory neurotransmitter necessary for impulsive behavior control.

  • Strategy: Behavioral relaxation techniques (e.g., deep breathing) that increase GABA can help reduce impulsivity.

• Norepinephrine:

  • Effect: Influences alertness, the fight-or-flight response, and attention.

  • Focus: In ADHD, interventions target managing norepinephrine-driven impulsivity.

Defining Challenging Behavior

• Definition: Challenging behaviors include behaviors that disrupt social norms, can cause harm, and influence learning or living conditions.

• Interference with:

  • Occupational engagement

  • Participation in daily activities

  • Learning and developmental processes

  • Social interactions

• Reference: Case-Smith & O'Brien (2020, Ch. 21)

Prevalence of Behavior Problems

• Research indicates that 10%-15% of children in early childhood programs exhibit clinically significant behavior issues (Park & Scott, 2009).

• In individuals with ASD, prevalence rates of challenging behaviors range from 35.8% to 94.3% (Baghdali et al., 2003; Jang et al., 2011; Matson et al., 2009).

Types of Challenging Behavior

Passive Behaviors

• Noncompliance: Child continues to play instead of following instructions.

• Withdrawal: Child sits quietly avoiding interaction.

• Avoidance: Child frequently asks to go to the bathroom to escape tasks.

• Inattention: Child distracts themselves instead of completing tasks.

• Lack of Response: Unresponsive to verbal instructions.

Active Behaviors

• Direct Refusal: Child expresses refusal and pushes materials away.

• Aggression: Child exhibits physical aggression, such as hitting or throwing.

• Self-Injurious Behavior: Child inflicts harm on themselves when upset.

• Opposition: Child acts contrary to instructions, like running away.

Behavior Theory Overview

• Components:

  • External stimuli

  • Responses to those stimuli

  • Consequences of those responses

• Learning Process:

  • Individuals determine which behaviors yield positive versus negative outcomes.

  • Behaviors leading to pleasurable outcomes are reinforced and likely to recur.

A-B-C Relationship

• A: Antecedent: Events prior to the behavior.

• B: Behavior: The observable actions, including topography, frequency, and duration.

• C: Consequence: Results following the behavior, impacting its future occurrence.

Setting Events

• Definition: Conditions that increase behavior likelihood, which may not directly cause behaviors but make them more probable.

• Internal Factors: Hunger, fatigue, illness, anxiety.

• External Factors: Changes in schedule, unfamiliar environments, increased task demands, sensory stimuli.

Purpose of Behavior

• Behaviors typically aim to achieve one of the following:

  • Attention: Seeking interaction or recognition.

  • Escape: Avoiding tasks or situations.

  • Tangible: Obtaining an object or activity.

  • Alone/Nonsocial: Preferring to avoid interaction.

  • Sensory: Seeking sensory input (automatic reinforcement).

Functional Behavior Assessment (FBA)

• Definition: Systematic process to identify variables maintaining a behavior.

• Goals:

  • Identify antecedents and consequences.

  • Determine behavior functions.

  • Develop intervention strategies.

• Importance: Enables clinicians to understand behavior genesis, leading to tailored interventions.

FBA Process Steps

1. Team Formation & Goal Setting: Identify team members and outcomes.

2. Functional Assessment: Collect data on behavior context and circumstances.

3. Hypothesis Development: Analyze potential functions of the behavior.

4. Behavior Support Plan (BSP): Design tailored intervention strategies.

5. Implementation & Monitoring: Execute plan, observe outcomes, and adjust as necessary.

Behavioral Interventions

• Aim:

  • Build desired behaviors

  • Reduce challenging behaviors

• Methods:

  • Antecedent Interventions: Preferred as they can prevent problematic behavior.

  • Consequence Interventions: Focus on behavioral outcomes after incident.

Antecedent Interventions Defining Features

• Modify conditions occurring before behavior manifestation, aiming to prevent issues.

• Benefits include enhancing functional behavior time and fostering a positive learning environment.

Common Antecedent Approaches

• Setting clear rules and expectations.

• Maintaining predictable schedules to support transitions.

• Consistently arranging the environment and providing praise.

• Allowing for movement opportunities and reducing waiting times.

• Individualized Approaches:

  • Tailor tasks to developmental levels, allow for choices, use individual interests, and modify sensory features.

Functional Communication Training (FCT)

• Definition: Method for teaching effective communication.

• Objective: Achieve objectives that were sought through challenging behaviors.

• Examples: Asking for breaks, needing help, or expressing discomfort using picture cards or gestures.

• Outcomes: FCT enhances communication alongside self-efficacy and empowerment.

Pivotal Response Training

• Focus: Training pivotal behaviors crucial for success across scenarios (e.g., motivation, initiation).

• Example Skills: Requesting help, responding to cues, yet learned in low-pressure settings to optimize success.

Environmental Modifications

• Aim: Minimize triggering conditions for challenging behavior during high-demand or sensory-rich moments.

• Examples: Use of visual schedules, timers, representational objects, seating adjustments, and sensory distraction management.

Visual Schedules

• Description: Provide visual representations of daily routines, workouts, and tasks for clarity.

Timers and Techniques

• Example: Pomodoro Technique - manage work periods of 25 minutes followed by 5-minute breaks.

Positive Behavioral Interventions and Supports (PBIS)

• Framework: Utilizes behavioral principles and environmental modifications to encourage positive behavior.

• Three Tiers of Support:

  • Tier 1: Universal for all; includes organized environments and social-emotional learning.

  • Tier 2: Targeted supports for at-risk students, such as social skills groups and check-in systems.

  • Tier 3: Individualized supports including FBA and tailored intervention plans.

Consequence Interventions

• Focus: Address outcomes following behaviors.

• Common Methods:

  • Punishment: Adverse consequences post-behavior (not effective).

  • Extinction: Removing reinforcers for undesired behavior.

  • Reinforcement: Reward-based strategies to shape desired behaviors.

Reinforcement Strategies

• Positive Reinforcement: Addition of desirable outcomes to increase behavior (e.g., praise).

• Negative Reinforcement: Removal of discomfort to enhance behavior (e.g., allowing breaks).

• Differential Reinforcement: Strengthen desired behaviors while removing reinforcements for challenges.

  • Types include DRI (Incompatible), DRA (Alternative), DRO (Other behavior).

• Noncontingent Reinforcement: Delivering reinforcement at predetermined intervals to preemptively reduce the need for challenging behavior to gain outcomes.

Contingency Methods

• Employing an “if-then” perspective (e.g., complete tasks to earn a fun activity).

Token Economies

• A system rewarding children with tokens for good behavior exchangeable for rewards (e.g., playtime).

OT Perspective and Collaboration in Behavioral Approaches

• Role of OTs: Integrates behavior theory with occupational-centered approaches, recognizing sensory and emotional aspects of behavior.

• Contributions include individual and environmental modifications to improve engagement and minimize disruptions.

Collaborative Roles in Behavioral Support

Assessment Tools in Pediatric Occupational Therapy

Diagnosis Spotlight: Fetal Alcohol Spectrum Disorder (FASD), Conduct Disorder & Oppositional Defiant Disorder (ODD)

Fetal Alcohol Spectrum Disorder (FASD)

• Definition: A range of conditions resulting from prenatal alcohol exposure affecting brain development.

• Subcategories:

  • Fetal Alcohol Effects (FAE)

  • Alcohol-Related Neurodevelopmental Disorder (ARND)

  • Alcohol-Related Birth Defects (ARBD)

• Prevalence: 1.5 to 4.5 per 1000 live births, preventable with abstinence during pregnancy.

Impact and Challenges of FASD

• Neurological/Cognitive: Issues include executive function deficits, impulse control problems, attention difficulties, and cause-effect reasoning challenges.

• Motor and Sensory: Involves coordination issues, sensory processing challenges, and delayed motor skills.

• Learning Implications: Skills may not generalize and require structured repetition for effective learning.

Conduct Disorder

• Prevalence: 1%-4% in children ages 9-17, more common in males.

• Definition: Persistent rule violations and disregard for others’ rights, linked with impulse control and emotional regulatory deficits.

• Criteria: Among behaviors for diagnoses include aggression, property destruction, deceit, and rule violations.

Oppositional Defiant Disorder (ODD)

• Definition: Consistent hostility or defiance towards authority that lasts more than 6 months.

• Symptoms: Argumentativeness, irritability, blaming others, and difficulty in friendships.

• Co-Occurrence: ADHD, anxiety, and mood disorders can co-occur with ODD.

Diagnosis Considerations