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April 2, 2005

El Sumario en la Espanol



A. Functional Behavioral Assessment (Understanding Behavior)
B. Preventing Challenging Behaviors by Enhancing Quality of Life
C. Teaching/Encouraging Desirable Behavior
D. Intervention when Difficult Behavior Occurs 
E. Managing Crisis Situations (if necessary)
F. Evaluating Behavior Support Efforts 
G. Supporting Caregivers 

Positive Behavior Support (PBS) is an approach to helping people improve their difficult behavior that is based on four things:

  1. An Understanding that people (even caregivers) do not control others, but seek to support others in their own behavior change process;
  2. A Belief that there is a reason behind most difficult behavior, that people with difficult behavior should be treated with compassion and respect, and that they are entitled to lives of quality as well as effective services;
  3. The Application of a large and growing body of knowledge about how to better understand people and make humane changes in their lives that can reduce the occurrence of difficult behavior; and
  4. A Conviction to continually move away from coercion – the use of unpleasant events to manage behavior.

Coercion involves attempting to control the behavior of others through threat of, or escape from unpleasant events. Coercion minimizes the dignity of the other person, often provokes retaliation, and sometimes causes physical and emotional harm. One example of coercion involves overpowering someone and physically forcing him to do something he doesn’t want to do. If he doesn’t comply, he is forced and continues to be forced until he gives up fighting. A common and relatively minor example includes taking privileges away from a person when she misbehaves. However, even minor coercion can be harmful in that it can take away from the dignity, autonomy, and sense of self-control of the other person. Equally important is that when minor coercion that was once effective ceases to work, caregivers tend to increase the level of coercion rather than decrease it. They may increase the length of time required to spend in time-out, the amount of privileges taken away, or the tone of voice used.
PBS involves a commitment to continually search for new ways to minimize coercion. This does not mean parents or caregivers should be judged harshly if they occasionally resort to yelling. We all fall back on patterns of caregiving that have worked for us in the past, especially when we are challenged by difficult behavior. PBS simply means that we, as caregivers, recognize the times when we have resorted to coercion, and continually seek to find alternatives that we can use next time we’re challenged with similar behavior.
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Many people with difficult behavior have been misunderstood and mistreated throughout our history. People with developmental disabilities, in particular, have been subject to a wide array of disrespectful, humiliating and even painful, conditions in the name of “effective treatment”. In recent years, however, there has been a growing body of research that demonstrates that even the most challenging behaviors can improve with the help of one or more of the approaches outlined below. The combination of these is the field called Positive Behavior Support. This document is an attempt to summarize current knowledge in the field so that more families/caregivers and providers can know that there are alternatives to punishment, and what those alternatives are.
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  1. Functional Behavioral Assessment (Understanding Behavior)

Functional behavioral assessment (FBA) is the process of learning about people before intervening in their lives. It is a systematic process for describing difficult behavior, identifying environmental factors and setting events that predict the behavior, and guiding the development of effective and efficient behavior support plans. FBA is the foundation of positive behavioral support. Three important beliefs underlying FBA are:
1. All behavior that persists serves some purpose,
2. Every person is unique, and
3. The best way to help someone change their behavior is to first understand the reasons behind the behavior.
One of the misapplications of behavior analysis has been the wide-spread use of behavior management, or behavior modification, procedures that prescribe consequences for difficult behavior without first assessing the reasons for the behavior. The need for FBA can be seen when two different people display the same behavior for two different reasons. One person may run away from a caregiver when asked to perform a certain task because he has learned to avoid the work by running away. Yet another person may show the very same behavior because she has learned that she can get individual attention from the caregiver (e.g., being chased and brought back) when she runs away. The intervention methods chosen for these two individuals should be different based on their unique assessments, rather than the same based on the similar appearance of their behavior. Unfortunately, without a functional behavioral assessment people with similar behaviors tend to be treated with similar consequences. Many things go into a comprehensive FBA. These include:
Clear Description of the Behavior
What does the challenging behavior look like? What does it sound like? Does it occur in conjunction with other behaviors or in isolation? Is there any warning? How long does it last? How long has it been a problem? Similarly, what would an alternative desirable behavior look/sound like?
Typical Routines
When is the challenging behavior more likely to occur? When is it less likely? What are the activities or expectations, and with whom does it occur? It is also helpful to ask these who, what, when and where questions of the alternative desirable behavior.
A rationale is needed for why the behavior is deemed difficult and why it requires change. Sometimes minor infractions are viewed as major problems by one caregiver but insignificant by others. Is the behavior harmful to self or others, or is it merely distracting? Sometimes the questions must be asked, “Whose problem is it?”
What skills does the person have that could become a source of success and esteem? These are often the very behaviors that are viewed as difficult. For example, a student with boundless energy may not be able to sit still in class, but could become a tremendous help to the crew that cleans the cafeteria tables. What limitations does the person have that prevent her from accomplishing the simple things, and achieving the recognition that other girls take for granted?
What kinds of events, books, movies, foods, music, etc., does the person enjoy? What does he hate? Some behavior challenges are nothing more than a statement of preference or refusal for people who cannot speak or be heard otherwise. Understanding what a person enjoys can help to break up the day and serve as a means to connect with others.
Who are the heroes in this person’s life? Does he value the qualities found in TV action characters, in his father or uncle, in her grandmother, or the popular girls at school, and what are those qualities? How do the values and routines of the immediate family, extended family, neighborhood or village, impact the individual’s behavior? Does she find greater importance in caring for a baby or sick grandmother than in attending school or getting to work on time? Is he a part of a group where loyalty to a family or gang member is demonstrated by getting even? Does the school culture encourage using words to tell the teacher, or not tattling and using fists?
Biomedical/Physical Factors
Ear infections, stomach aches, headaches, over-sensitivity to certain sounds, hunger, fatigue, over-stimulation, boredom or the way things feel to the touch, can all vary among individuals. Yet these factors can be a significant reason for many behaviors like head banging, chronic whining, striking out at others, or running out of a room. The person’s diet and medications are also important considerations, as are things like depression, attention deficits, seizure disorders, and many more. Understanding specific disabilities and their impact on behavior is a necessary requirement of any FBA.
Environmental Factors
Do the challenging behaviors occur more in some settings than in others? Do they occur less in some settings? Differences in noise level, the density of the crowd, the expectations of the setting (e.g., a classroom versus a playground), can all make a difference. Is the person’s schedule too unpredictable? Is it too predictable? Does she do better in warm weather or cold, bright sunlight or indoors? Do shirts with collars or certain fabrics irritate the skin and increase challenging behavior? Both the physical and social environments should be considered here.
What does the person gain through her behavior? Does she get attention, assistance, food or objects that she wants? What does he escape or avoid through his behavior? Does he get out of doing chores by complaining? Does he avoid a scolding or grounding by lying? Also, what is the motivation for behaving? Does working hard pay off? Does telling the truth? Does dressing himself result in any greater reinforcement than remaining dependant on others to dress him? Does “good” behavior go unnoticed while “bad” behavior gets an immediate reaction? This is one of the most significant factors to consider in any FBA and should include a description of the setting events, antecedents and consequences of the behavior.
Intervention History
A good assessment also seeks to learn from the past. What has worked and what hasn’t worked are important questions to answer, as are who has helped and who has not. Also, many people with challenging behaviors have been treated harshly for years, or have experienced severe trauma at some point in their lives.
Learning History
What has the person been learning through her history of displaying difficult behavior? Has she learned, for example, that “good” behavior goes unnoticed while “bad” behavior gets an immediate reaction? Has he learned that the longer he persists at complaining, fighting or tantruming, the more likely he is to get his way?
Learning Style
How does the person learn best? Can she follow simple or complex instructions? Can he translate what he hears into action, or has he learned to tune out verbal instructions. Does she learn best by seeing, feeling, doing, or by teaching others?
Many people with developmental disabilities and difficult behavior have few meaningful relationships that are lateral rather than hierarchical, that are equitable rather than inequitable, and that involve people in their lives who are not reimbursed in some way for their time. To what type of person is the individual attracted? What type of people does she avoid? Meaningful peer relationships are critical for social development and quality of life.
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  1. Preventing Challenging Behavior by Enhancing Quality of Life

Many behaviors we view as challenging are nothing more than a logical reaction to an illogical life. People with challenging behavior often have minimal control over where they live, with whom they live, what they do for a living, what they have for dinner, and so on. Simply helping people who depend on others for support to dream of and live the kind of lives that most people take for granted, can reduce challenging behavior tremendously. All prevention approaches listed below should occur in the context of the person’s real-life settings. That is, these approaches include things that can be done by or for the individual in the classroom, in the home, in the car, on the street, in the park, supermarket, and other real-world settings, rather than in the clinic. If skills are to be taught in a clinic setting, then specific strategies should be included that will ensure generalization to the natural settings.
Person-Centered or Family-Centered Planning
Full participation in dreaming of a desired future and charting the course needed to get there, with the encouragement and support of people closest to us, is something many of us do on a continual basis. Similar options must exist for people who challenge the service system. Focusing on the strengths of people or their families, and on other people around them who might help, is a necessary step to improving behavior.
Exposure to Options
True choice does not exist unless it is informed choice. However, simply telling people of the variety of living arrangements, jobs, entertainment options, and other life choices available to them is usually not sufficient. Many people must repeatedly see, touch and feel a wide variety of experiences in order to truly have informed choice.
Exposure to Appropriate Role Models
We are all influenced by the people with whom we live, work, eat, play, etc. Fortunately, most of us are able to learn by watching and listening to others, rather than having to experience everything for ourselves. Helping people improve their behavior is as much about inspiring them as it is about instructing and rewarding them. If the peers and caregivers in a person’s life are not good examples, then it only makes sense for the individual to set his sights low. If, on the other hand, the person is included with others at school, at work, and in the community who are good role models, she will set her sights higher.
Exercising Choices
Many people with challenging behavior do not have much experience making choices about minor daily events (much less about significant life goals), and having those choices respected. Challenging behavior often arises from a lack of choice about what to wear, what to eat, what to watch, or where to go for fun. Repeated practice in exercising choices builds a sense of competence and prevents many challenging behaviors.
Assistive Technology and Supports
Challenging behavior often results from heavy dependence on others for such things as personal hygiene, transportation, information, communication, and entertainment. Assistive technology and other accommodations can result in far less dependence on others, fewer reminders, and fewer behavioral challenges. Assistive technology can include a communication device for those who cannot otherwise get their needs met, or listening to a book on tape for those who have trouble reading, or a watch with several alarms for those who have trouble remembering.
A Sense of Belonging
Are there certain people, or groups of people, with whom the individual feels most at home? What feedback from others best communicates a clear message that she is appreciated for who she is? Does he feel any sense of belonging to the classroom, the school, and the residential or neighborhood community? Or does he feel most accepted by a local gang? Who accepts him unconditionally, and who requires him to earn his place?
Altering the Environment
Some people benefit by organizing different settings in such a way that each environment is associated with different expectations and activities (e.g., eating, group activities, private space, free time, etc.). For others, simply minimizing distraction, playing calm music or eliminating background noises, can make a meaningful difference in challenging behavior. Environmental modifications help most when the antecedent events that provoke challenging behavior are avoided, as well as the consequences that reinforce the behavior.
Addressing Biomedical or Physical Factors
Sensory integration such as deep pressure, joint compression, brushing or swinging, can help many people become more receptive, ready to learn, and less distractible. Medications to reduce seizure activity, impulsiveness, infections, depression or hyperactivity, are also necessary for some people. Adequate sleep, proper nutrition, physical exercise, and pain management are other important factors to consider.
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  1. Teaching/Encouraging Desirable Behavior

Establishing Helpful Routines
We are all creatures of habit. Some people rely more heavily on routines than others. Some become extremely frustrated when their routines change. Helping people establish predictable routines around personal care, eating, dressing, working, and transitions are all important elements of PBS. Printed or picture schedules are some ways to let a person know what’s coming next.
Building a New History of Success
Many people with challenging behavior have experienced failure throughout their lives. Helping people recognize and celebrate their successes, no matter how small, can help them become more open to trying and more positive about themselves. Attempting to build a history of success by filling a person’s day with more rewards for the many accomplishments that often go unnoticed, rather than corrections for all the challenging behavior, is extremely important.
Setting Realistic Expectations
Many behavior problems arise from expectations that cannot be met. For example, it is unrealistic to expect someone with difficulty understanding and sequencing auditory information to follow verbal instructions involving multiple steps. It is also unrealistic to expect someone who cannot sit still for more than five minutes to behave during a one-hour assembly. Setting realistic expectations also includes not setting expectations too low that people are not challenged, and raising expectations when new skills are learned.
Clarifying Expectations
Often, it is not that the expectations are too difficult or too hard, but that they are not understood. Using pictures to represent the steps in a person’s schedule can be extremely helpful for some people. Objects are needed for others when the pictures don’t have any meaning. Still others may fully understand written and spoken language, but may need to be taught such things as making eye contact when spoken to. Some people do not know that others prefer it when you look at them. Many people get into trouble simply because they “don’t know any better.”
Teaching and Reinforcing Effective Alternative Behavior
Any behavior that persists over time serves some purpose. It is unrealistic to expect people to stop doing something that works for them without giving them something to do in exchange. If an individual hurts herself to escape from the noise and the crowd of the dinner table, then she should be taught another, equally effective way she can ask to be excused from the table. This could be signing, pointing to a symbol taped to the table, or pressing a button on a communication device. Furthermore, whenever she attempts the new behavior, her communication should be honored and she should be allowed to escape.
Teaching Behaviors that are Naturally Reinforced
Our goal is not to create dependence on caregivers, but to teach skills that are valued and rewarded by others. If a person misbehaves in order to get attention from the teacher, then teaching her to say, “Teacher, how am I doing?” may be naturally rewarded by the teacher’s response. One of the most powerful, yet seldom-taught class of behaviors is the skill of rewarding others by smiling, hugging, saying thank-you, or complementing them. For many people, these behaviors need to be taught directly.
Fading the Supports Needed for Desirable Behavior
Too often we assume that once new behaviors are taught, people will automatically use those behaviors on their own. Unfortunately, this is seldom the case. Fading first the prompts and then the rewards is a necessary step to any lasting behavior change, and is a skill that caregivers must develop. If the only time a person who is teased by others uses words instead of fists is when a caregiver is present to remind him, then our work is not finished.
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  1. Intervening when Challenging Behavior Occurs

All intervention approaches listed below should occur in the context of the person’s real-life settings. That is, these approaches include things that can be done by or for the individual in the classroom, in the home, in the car, on the street, in the park, supermarket, and other real-world settings rather than in the clinic. If skills are to be taught in a clinic setting, then specific strategies should be included that will ensure generalization to the natural settings.
Preparing Oneself for Challenging Behavior
Knowing those behaviors and situations that challenge us the most is a necessary step for supporting people who hurt us, embarrass us, scare us, or offend us. We can avoid negative and emotional reactions best when we purposefully and consciously plan how we wish to handle a given situation. We can act more compassionately when we remember the message behind the behavior. It is when we are caught off guard that we make the most mistakes.
Minimizing the Power of Challenging Behavior
We often do not know why a given behavior persists. It may be reinforced by attention of caregivers or of peers. It may be reinforced by escape from demands, or by getting one’s way in a power struggle. It may be a combination of all of those things. For this reason, it is best to minimize the power or the impact of the challenging behavior when it occurs. Not acknowledging the behavior, not allowing it to interrupt the group or change your focus, not providing a reaction, or giving in to the demands of the individual are all ways to minimize the power of the challenging behavior and diffuse a dangerous situation.
Interrupting Challenging Behavior (if necessary)
The purpose of interruption is to help the individual stop the challenging behavior or to minimize the harm caused by the challenging behavior. Examples include removing someone from the room to stop the disruption her behavior is causing others, or blocking blows to the head to minimize injury to self. Not all behaviors require interruption. Many can be ignored or redirected, or are brief isolated events that occur once and are done. When interruption is necessary, it should be done gently, safely, and calmly.
Redirecting to Effective Alternative Behavior
At the same time we strive to minimize the power of the challenging behavior, we must often remind people of what they could be doing instead to get their needs met. Redirection can take the form of verbal reminders, pointing to one’s schedule, handing the person his coat, and much more. The purpose of redirection is NOT just to stop the challenging behavior, but to remind people that doing something else will get their needs met.
Reinforcing Effective Alternative Behavior
No ignoring, redirecting, or interrupting approach will be successful if it is not accompanied by the reinforcement of effective alternative behavior. The child who is redirected to raise his hand rather than shouting out in class had better be called on when he does raise his hand. If telling the truth is preferable to lying, caregivers must find a way to reinforce truth-telling, even if the behavior admitted to was horrible. If using words or pictures to communicate is preferable to screaming and tantruming, then the reinforcement for communicating with words or pictures should be more powerful than the reinforcement they get for screaming and tantruming.
Using Consequences (if necessary)
There are times when all of the above approaches are still not enough to prevent or teach the person that the challenging behavior is no longer necessary or effective. When that happens, we need to increase our understanding of the function of the behavior and keep trying new ways to prevent and/or redirect. At those times, we should get an another perspective from someone who is objective and skilled in PBS. As we continue to seek new and effective positive approaches, it may be necessary to impose some consequences for the challenging behavior. While consequences that a person finds undesirable are a form of coercion that many of us try to avoid, there are times when caregivers need to do something to manage the behavior while other positive solutions are being sought. In those situations, it is best to use consequences that are planned in advance, rather than imposed as a surprise or as retaliation. Preferably, the person would be involved in discussing and deciding on the consequences before hand. Consequences for challenging behavior should also be relevant to the behavior, such as cleaning up a mess after having made a mess. Consequences should be respectful in that they don’t shame or humiliate the person, and they should be reasonable (e.g., giving someone else one’s video privileges for the rest of the day rather than the rest of the month). Lastly, they should provide opportunities for the person to practice the desirable behavior more often, not less often. If someone bullies others, then a consequence might be supervised practice helping others (e.g., turn-taking, holding the door open, complementing, carrying books, etc). The advantage of this is that the person has more opportunities to experience the rewards that go along with kindness, rather than fewer opportunities.
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  1. Managing Crisis Situations (if necessary)

All crisis management approaches listed below should occur in the context of the person’s real-life settings. That is, these approaches include things that can be done by or for the individual in the classroom, in the home, in the car, on the street, in the park, supermarket, and other real-world setting rather than in the clinic. If skills are to be taught in a clinic setting, then specific strategies should be included that will ensure generalization to the natural settings.
Stopping Harm to Self or Others
When challenging behavior becomes violent or self-injurious, what options does the caregiver have to help the individual, while also protecting the rights of others? Should the person be removed and if so, how? Where should she go and for how long? Should she be alone or supervised? Should we talk to her or not? What are the expectations of the person while she is removed? What are the expectations of the caregivers? Whatever the actions of the caregivers, they should be calm, unemotional, and not use excessive force.
Seeking Help from Others
When should we seek help from others? Should it be when the individual’s behavior has become dangerous or when the caregiver’s reactions have deteriorated and are no longer therapeutic? How do we communicate that need for assistance? What are the roles that others should play? Should the principal be the stern disciplinarian or the kindly big brother? How about the police, probation officer, judge, grandmother, etc.? What are the best methods to ensure that others involved understand the individual and the goals of the behavior support plan?
Dealing with Others’ Expectations
Often, caregiver reactions to crisis situations are influenced more by the expectations of the people in the supermarket or the other students in the classroom than they are by what is the most effective way to deal with the behavior. Outside observers are quick to make judgements such as “spoiled child,” or “that’s not fair,” and those judgements do affect how we respond to challenging situations. Caregivers need tools to deal with the expectations of others, whether real or perceived, if they are to be effective in helping the individual gain control of his behavior.
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  1. Evaluating Behavior Support Efforts

Any PBS plan should be a living document serving as a tool for families/caregivers and subject to changes when needed. As with the development of the original PBS plan, any changes to the plan should be based on information reflecting the success or lack of success of the plan, or changes in the individual’s behavior or life circumstances. Monitoring, evaluating, and revising PBS plans should include the following:
Objective, Observable, Measurable Data
Has the number of times that the person runs away decreased or increased? Has the duration of the tantrums decreased or increased? Has the rate of using the communication device increased? Has the rate of hurting others to communicate decreased? Any decisions about whether the plan is working or not should include objective and measurable data.
Monitored Continually
Data on both challenging behavior and the desirable alternatives should be monitored on a regular basis (e.g., collected every day, graphed, or summarized each week). Baseline data (before the PBS plan began) should be collected over time and compared to Intervention data (after the PBS plan began), also collected over time. Any decisions about whether the plan is working or not should be based on consistent data gathered over time, rather than on single and subjective observations or impressions
Revised when Data Indicate and when Team Decides
Frequent changes to PBS plans are not recommended. Often, it takes several days or weeks to determine if the elements of the plan are working. Decisions to change any components of a PBS plan should be based on what the data indicate, and should be made in collaboration with the other team members rather than by individual caregivers. If it is not clear whether the behavior is improving, it may be best to continue the plan without change until the effects of the plan become clear. If it is obvious that the behavior has become worse, changes should be considered sooner. One important piece of any decision to change or revise a PBS plan is whether or not the plan has been implemented as intended. Are rewards sincere, are caregivers truly calm and unemotional when challenged? Has the plan been implemented in the spirit in which it was developed?
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  1. Supporting Caregivers

All caregivers, whether parents, teachers or direct support personnel, play some role in encouraging or discouraging difficult behavior among the people in their care. Caregivers expected to implement behavior support plans should be involved in the assessment process, in developing and in evaluating those plans, although they are frequently excluded. Even in the best of situations, however, caregivers need ongoing support in order to remember what they should do and why, to be relieved during difficult times, and to be encouraged for weathering through those times.
Involving Caregivers in Plan Development
Often the people responsible for day-to-day implementation of behavior support plans are not involved in the assessment or plan development, and have not had the opportunity to have their opinions considered or their questions answered. Unless provisions are made to help the caregivers understand why they’re asked to ignore some behaviors and respond to others, they will most certainly make mistakes.
Understanding Caregiver Values/Culture/Beliefs
Sometimes caregivers are expected to compromise their own values when supporting someone with challenging behavior. A simple, but common example of this is asking someone who has strong objections to cursing to “just ignore it.” While it may seem like an easy thing to do for some caregivers, it creates a great deal of stress for others.
Providing Training and Technical Assistance
It is not enough to tell caregivers what to do, or to give them a behavior support plan to read. They need to be able to ask questions, watch someone demonstrate, receive frequent reminders and frequent feedback on how they’re doing.
Providing Effective Role Models
Helping someone improve her behavior can be a slow process, with subtle and often unrecognizable changes in the person’s behavior. It is healthy for caregivers to focus on the quality of the care they provide as their source of satisfaction, rather than focusing only on the desired changes in the other person’s behavior. After all, the only thing that caregivers have control over is how they live up to their own expectations. Unfortunately, many caregivers don’t have high expectations of themselves. They have never seen someone deal with violent behavior gently and effectively. They don’t know that there are alternatives to retaliation or restraining people. By providing effective role models, caregivers are sometimes inspired to be better, and to set their expectations higher.
Providing Frequent and Relevant Feedback
Knowing that the person supported is doing better is a reward that often keeps caregivers hanging in there. Sometimes that improvement is very small and goes unnoticed. Sharing charts and graphs with the caregiver that documents improvement can be an effective reward for her efforts. Many times, however, the behavior change comes too late, and the caregiver finds herself frustrated and burned out before any real progress is noted. Feedback should also focus on how the caregiver behaves. Do his rewards outnumber corrections? Are his instructions more effective? Has he been more patient, even though the person’s behavior has not yet improved?
Ensuring Caregivers have Ongoing Emotional Support
All caregivers need the opportunity to share frustration when the stress becomes too great, to grieve when they have failed to live up to their own expectations, and to celebrate when they have been successful. This support may come in the form of parent groups, relationships with fellow teachers or direct support personnel, email discussions, exercising, reading books, membership in religious communities, and much more. Whatever form it comes in, all caregivers need some way to obtain emotional support in order to prevent them from burning out.
Responding to Caregiver Requests in a Timely Fashion
Caregivers need to know there is help available to them when they need it. It may be the school counselor or psychologist. It may be the service coordinator or respite provider. Whoever they trust to help them with challenging behavior, that help needs to be available soon after the request. It is when requests are not honored that caregivers stop asking.
Providing Opportunities for Professional/Personal Growth
Caregivers need the chance to grow as individuals, separate from the people they support. This growth may include the chance to reflect on and refine one’s professional leadership skills or one’s spiritual beliefs. It may be attending a conference or reading a good book. Regardless of the form, caregivers must have an avenue to learn and grow in ways that best meet their needs.