Exploration of Challenging Behaviors in Pediatric OT

Abstract

Date Presented 03/28/20

When children receive OT, they are expected to willingly engage in tasks that are difficult. This is often not the case. This research surveyed OTs nationwide to examine the impact of challenging behaviors on a child’s therapy participation. Results indicated that children primarily exhibit behaviors to escape the demands of therapy, with therapists expressing safety concerns, lost time, and frustration. Knowledge and feasibility of an evidence-based behavioral intervention were also explored.

Primary Author and Speaker: Sandra Brown

Additional Authors and Speakers: Claire Cote, Ashley Mills, Brooke Page, Sheila Norris, Brooke Whitley

PURPOSE: When a child struggles with self-care, play, education, and/or social participation, they often receive occupational therapy (OT) to assist with skill development. Typically, when frustrated or upset, children engage in behaviors that are not considered socially appropriate (e.g. temper tantrums). If a child has impairments or delays, activities that are considered fun and enjoyable are actually challenging, or avoided. Yet in therapy, the child is expected to participate willingly in the very activity that is difficult for them.

Most recent data from the National Survey of Children’s Health (Child and Adolescent Measurement Initiative [CAHMI], 2017) reported that over 10 million children in the United States have a health condition that affects their participation in daily activities. Fifty-eight percent also have emotional or behavior difficulties (CAHMI, 2017). Over 5 million children are currently receiving specialized services, such as speech, occupational, or behavioral therapy to address developmental needs (CAHMI, 2017), so a behavioral response should be anticipated, even expected.

There is significant evidence in the literature of successful reduction of maladaptive behaviors (Hagopian, Hardesty & Gregory, 2015). However, the focus is on the behaviors specifically, not the impact the behaviors have on a child’s engagement in daily activities (Matson, Hattier, & Belva, 2012; Welch & Polatajko, 2016). The purpose of this research was to probe pediatric OTs across the country to discover how a child’s behavioral responses impact therapy participation. This investigation also explored what strategies therapists are using to address behaviors, and their knowledge of an evidence-based behavioral intervention.

DESIGN: This research was conducted using an online anonymous survey. Pediatric occupational therapists and therapy assistants were recruited through the American Occupational Therapy Association members-only “CommunOT” discussion boards, social media, and publicly available email addresses. Snowball sampling was utilized to maximize distribution.

METHOD: The survey included open and closed-ended questions such as types of behaviors observed, diagnoses treated, work setting, knowledge of behavior interventions, strategies used, self-efficacy, and feasibility. Quantitative analysis included descriptive statistics (e.g. frequency) and examined associations between related variables (e.g. practice setting and behaviors observed). Qualitative responses were analyzed thematically.

RESULTS: Preliminary results were collected from therapists in all 50 states (n = 498). Over 87% indicated challenging behaviors impacted therapy sessions at least sometimes. Avoiding difficult tasks (74%) and requests to perform difficult tasks (67%) were the most frequent reasons for behaviors. Most common behaviors observed included impulsivity (63%), self-stimulatory movements (54%), and inattentiveness (46%). Therapists expressed safety concerns, inability to complete tasks, and increased time burden when children exhibited behaviors. Strategies reported included visual schedules, ignoring behaviors, and sensory activities.

CONCLUSION: Nationwide, therapists expressed considerable concerns with behaviors impacting therapy. Overall, children exhibited behaviors to escape the demands of therapy. Therapists are using a variety of strategies to address behaviors, expressing their own challenges and frustrations as a result. Impact Statement: Children demonstrate significant behavioral responses to therapy, which could lead to falling even further behind and participating in less activities that are typically part of a child’s life. Identifying and addressing best practices for behavioral intervention is pivotal.

References

Child and Adolescent Health Measurement Initiative. (2017). National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved from www.childhealthdata.org.

Welch, C. D., & Polatajko, H. J., (2016). Applied behavior analysis, autism, and occupational therapy: A search for understanding. American Journal of Occupational Therapy, 70, 1-5. DOI: 10.5014/ajot.2016.018689

Hagopian, L.P., Hardesty, S.L., & Gregory, M. (2015). Applied behavior analysis: Overview and summary of scientific support. Retrieved from https://www.kennedykrieger.org/sites/default/files/patient-care-files/aba-scientific-support-9-2015.pdf

Matson, J. L., Hattier, M. A., & Belva, B. (2012). Treating adaptive living skills of persons with autism using applied behavior analysis: A review. Research in Autism Spectrum Disorders, 6, 271-276.