Treatment or Accommodation for Adults with Challenging Behaviors

When an adult with developmental disabilities is referred for a significant behavior problem such as aggression, oppositional behavior, self-abuse, or destructiveness, it is customary practice in residential care settings to develop and implement a behavioral treatment plan that involves a number of interrelated steps. Typically, a history is taken to determine the strength of the behavior, circumstances related to its occurrence, and past efforts to treat it. Next, presently occurring and potentially contributing physical factors are addressed and ruled out to the extent possible by referral to appropriate medical professionals. The present status of the individual is then assessed through (a) direct observation in the individual’s natural environment; (b) interviews with the individual, when appropriate, and staff members, family, or others familiar with the person; and (c) relevant testing (e.g., as an evaluation of cognitive and adaptive skills and screening for psychopathology, Alzheimer’s disease, or other disorders) and identifying reinforcer preferences. A detailed functional analysis follows to obtain a baseline of the challenging behavior and to identify possible related environmental factors. At this point, internal factors that may be contributing to the problem behaviors as well as relevant psychiatric diagnoses are considered and, when appropriate, a referral is made for a consultation and possible medical management of the disorder. Finally, a behavioral treatment plan appropriate to the individual’s developmental level is designed and implemented, including appropriate staff training and monitoring. Typically, treatment programs involve procedures to reinforce behaviors incompatible with the challenging behavior and to apply least restrictive consequences for the referral problem. Broadly speaking, the objective of behavioral treatment is to make systematic changes in the individual’s environment, including antecedents and consequences, that will support the individual as new adaptive behaviors are learned and old problem behaviors are reduced and ultimately extinguished. The long-term goal of behavioral treatment is to have the individual maintain behavioral gains in the absence of continued treatment. The final outcome should be an improved quality of life for the person in treatment as well as the other residents and staff members whom this individual encounters on a daily basis. The professional literature is replete with studies that document the effectiveness of behavioral treatment programs, and practitioners can easily cite numerous successful treatment cases of their own. However, not all individuals with challenging behaviors experience positive treatment outcomes. We all have cases that despite our best efforts do not respond well to behavioral treatment and for some, they actually become worse. A number of factors contribute to poorer outcomes among individuals with developmental disabilities, including chronological age, a long history of problem behaviors, comorbid psychiatric diagnoses, medical complications, and an intractable treatment record. The purpose of this perspective is to suggest an alternative to traditional behavioral treatment programs that we have experienced good success with over the past 10 years. We call this approach accommo