Navigating the Behavioral Maze

We have done many behavioral interventions as part of our ABA program. The basis of these programs involves getting tokens for a targeted good behavior, such as sitting still in a chair for thirty seconds, and a reward for a certain number of tokens. This worked well for Elizabeth when she was a child. However, this method angered her terribly when we used it recently to try to help her get control of more serious behavioral issues.

After a year of struggling with escalating self-injurious behaviors (SIBs), we arrived at the Kennedy Krieger Institute at Johns Hopkins Hospital for three weeks of intensive, outpatient treatment. We worked with Elizabeth for ten minutes and then gave her a six-minute break, over and over again each day. It was exhausting both physically and emotionally.

During our initial consultation, the psychologist told us that Kennedy Krieger had never treated a child with SIBs and such high intelligence. This would be a new challenge for them. Here were the world leaders in behavior management, and they had never seen a child like this before? Although I love Elizabeth’s uniqueness, it would be nice if one time we could go to a doctor or therapist and hear them say, “No sweat. I’ve successfully treated this hundreds of times before and know exactly what to do to help Elizabeth.” It’s never happened.

What was clear to the psychologist was that the traditional behavioral reward systems were no longer appropriate for Elizabeth. Kennedy Krieger suggested using Cognitive Behavioral Therapy and Progressive Muscle Relaxation to help Elizabeth get control of her anger. These programs are used with adults, and they are more appropriate for her age and intelligence.

Over the course of many sessions, Elizabeth learned that her thoughts, feelings, and behaviors were interconnected and that she could change any of these three elements to affect the others and make a situation less stressful. Using the letterboard or Yes/No cards, we constantly sought her input about what was working for her. She told us that the muscle relaxation and positive, rational thinking were helpful to her. We nixed deep breathing exercises when she told us that they made her feel like she was under a doctor’s stethoscope.

More than anything else, I learned that this is just as much about changing how we treat Elizabeth as it is about how she learns to better regulate herself. Elizabeth needs us to stay calm at all times. We need to give her as much control as possible. It’s easy to impose our opinions on her, and the Yes/No cards avoid this by getting her input quickly. We need to treat her like the young adult she is and not talk about her, but rather with her, when she is present. If, despite our best efforts, she does get angry, we should give no response other than blocking the blows. Any other response reinforces the behavior.

We are early into our new behavioral interventions, but I already see changes in Elizabeth. She is calmer and happier. She still has flare-ups of anger, but they are less frequent and less intense. We have made enough progress that Elizabeth will return to school this year.