Adam J. Holstein, M.S., P.D., L.P.
Certified School Psychologist
Intervention is a matter of Perspective, Understanding and Training.
I was sitting in an Intermediate Care Facility many years ago. The Individuals were moving to a new home and an Aquarium with a ¼ of the water was sitting there with fish waiting to be moved as well. The water was dirty as the filter was unplugged. Present with me was an Occupational Therapist and Nurse. The Nurse commented that the dirty water was unhealthy, the Occupational Therapist O.T., indicated she was thinking there was not a lot of room to move about and I as the psychologist commented that they might be getting claustrophobic! (We each bring our own bias and perspective.) It is important to have a common language across disciplines such that interventions for any child be as consistent as possible. In my work in pre-schools, schools and programs under the auspices of the Office of People With Developmental Disabilities, OPWDD, I train teachers, clinicians and staff to understand these basic principles.
Applied Behavior Analysis is a tool/process that all of us are subjected to from birth and all of us are utilizing in our interventions with the children we teach and care for.
I believe human behavior and child development are inextricably intertwined. As such any intervention with a child is a highly complex task and one that is further complicated by the fact development is fluid (changing from moment to moment) as are the dynamics between teacher/clinician/parent and child.
I do not believe anyone intervention is the correct intervention for all children. There is simply too much we do not know. When it comes to a child having a disability or life challenge understanding a child becomes ever more complicated. Each child’s development is like a fingerprint. Understanding what part of a child’s development is biological and what part is learned is one of the major challenges in addressing a child’s needs and/or challenging behavior(s). Adjusting the interventions to be consistent with overall cognitive abilities, speech, receptive and expressive, gross and fine motor, sensory and social emotional development is critical to successfully helping the child realize his or her potential.
As a behavior therapist and psychoanalyst my bias and interventions focus on the social/emotional and behavioral needs of the child as a whole. In my limited understanding of the other disciplines I do my best to integrate the interventions being utilized in my behavioral treatment plan to support the child’s needs in each domain and to facilitate generalization of skills learned and those being taught.
My position here is to help address the social/emotional and behavioral needs of the child. To do that I integrate the teams understanding of each child’s behavioral/social emotional needs and development. To simplify this complex process, I begin by breaking down my understanding of a child’s behavior into 5 basic categories which then fantail into each discipline of a child’s development.
By performing a Functional Analysis of Behavior (FBA) the motivation of a challenging behavior, or any behavior for that matter, is understood. Behaviorally speaking most behavior is broken down into 4 basic categories and a 5th complex category. (Depending on your perspective any of the motivators are complex.) As they say; “Nothing in life is simple!”
As I delineate the following motivators, be mindful of the title, namely the Motivator is the Reinforcer!
1. Sensory in-put: Here I defer to our OT’s and PT’s and always seek to integrate a sensory diet into the behavioral program. It is critical to meet the sensory needs as an elemental level of development. If the child is not able to organize his or her world neurologically through the various sensory modalities, the child’s ability to understand his world and attend to the world will be compromised. The inability to organize the world and perceive the world and/or attend to objects in the world impacts on all areas of development. This includes the child’s ability to organize caregivers as meaningful people and establish a warm trusting relationship, which impacts on a child’s ability to separate from parents and/or transition from one place to another and feel safe. When designing any behavior program, I want to make sure the sensory needs are being addressed as best as possible, in treatment, in the classroom and home. My goal as much as it is feasible is to rule out sensory needs / rule out the communicative function of acting out, as motivation for the behavior. Conversely consistent with the O.T. and Physical Therapist, P.T., recommendations Sensory in-put is provided either at fixed intervals during the day and/or provided as a Reinforcer for appropriate/desired behavior(s).
2. Attention: is the second most basic need children have behaviorally speaking. We are all aware of the condition called Marasmus which is defined as:
Psycho-social deprivation is very common. Such neglect is not the same as abuse, although they are often said together. Unresponsive and apathetic children can inadvertently have their needs neglected. Neglect is usually failure of the two-way communication between the mother and child – not a willful act on the part of the mother. Mothers may not know how to care properly for their children. This is particularly common when the mothers were themselves neglected as children (so it is thought of as normal behavior) and where experienced elders are not present to teach the new or young mother. Fathers, through ignorance, often make such demands upon the mother that the child is neglected. All who are dependent on others for food and care are likely to suffer from neglect. Children in schools, hospitals and orphanages, the mentally ill or disabled, prisoners, and the elderly are particularly at risk.” From: http://www.abdn.ac.uk/medical/unicefprotect/marasmus
The contingent use of attention, in particular eye contact, holding, vocalizing, verbalizing and care through the consistent and constant emotional environment as well as ensuring health (bodily safety) and routines are all a critical structures which are part of caring, loving and attention. All of these components are interacting in microscopic and macroscopic ways shaping and forming feelings, behavior and personalities.
So when we are saying; “Oh he is acting out for attention.” We are stating that we are failing the child by not giving him enough attention AND/OR not giving him enough attention in whatever from, when he is behaving appropriately. So it is up to us to change our behavior. We have to ask ourselves, dynamically speaking; “Why would we give the child what he wants by his inappropriate behavior?” Again, we have to change our interaction(s) such that we are giving the child attention, when he or she is demonstrating the desired behaviors, thereby reinforcing these behaviors. (The Motivator is the Reinforcer!)
3. Tangible Gain: is where the child has learned that by acting out, yelling and screaming or demonstrating other challenging behaviors, he or she will get what he wants in terms of tangible objects. Examples of this can be seen in the supermarkets where a child will be yelling, screaming, falling to the floor (or worse) in order to get the food, candy or toy they desire. The parent in order to escape the embarrassment or not upset the child gives the child what he wants. This is true too of teachers and clinicians in schools and private practice. Here we want to provide the desired objects when appropriate behaviors are demonstrated. (The Motivator is the Reinforcer!)
4. Escape: is where the child gets out of doing something, a task or activity by demonstrating his challenging behavior. This can be an extremely challenging motivation, because once the child escapes he is reinforced. So here we have to be mindful to keep the demands limited with respect to level of difficulty and/or duration. Set goals within the child’s current ability and reinforce with escape or time to do as he or she pleases.
If life were so simple there would be no challenging behaviors. However, where Applied Behavior Analysis falls short too often, not all the time, is understanding the feelings behind the behavior(s) being demonstrated. This falls into the communicative function of the behavior, which in part includes the above motivators but something else. What is the child or person trying to tell us they are feeling?
5. The Communicative Function of Behavior: What is the child trying to communicate to us. What is his or her needs and/or feelings? Here the child’s level of speech development both receptive and expressive is critical. How do we communicate with the child our expectations, and how do we enable the child to communicate to us his or her needs and feelings?
In my Behavior Intervention Plans there is a direct line between our understanding of a child’s motivation and reinforcement for appropriate behaviors and a means to appropriately communication of his or her feelings and/or needs. There are proactive interventions and reactive interventions. It often boils down to; “Catching the child when he is Good!” Increasing the physical, social, verbal, tangible reinforcement when they are being good.
How much of any behavior we see is part of any given diagnostic category and how much is learned in the environment? This is also a critical line to understand and address. We also have to be mindful that any given behavioral challenge or behavior, has multiple motivations and teasing these out and addressing the need(s) is the science and art of a skilled clinician.
I am available to meet with school directors, clinicians in private practice and parents to discuss their needs and how to better serve the children they care for. I have offices in Manhattan and Great Neck. I provide staff training and consultation to schools and programs under the auspices of OPWDD.