Investigation of the Impact of Challenging Behaviors on Participation in Pediatric Rehabilitation

PURPOSE: Children with special needs may exhibit challenging behaviors (e.g., refusals, tantrums) that negatively impact participation in occupations. Pediatric occupational therapists, physical therapists, and speech-language pathologists assist with skill development for children with special needs who demonstrate difficulty engaging in learning, play, and activities of daily living. However, challenging behaviors may impact a child’s skill acquisition and successful participation in therapies if these behaviors are used as an adaptive response to decreased capacity in task performance. The purpose of this study was to conduct a preliminary investigation of the frequency and impact of challenging behaviors in a pediatric rehabilitation setting.

METHOD: This study had a quasi-experimental mixed methods survey design and included a convenience sample of therapists at a rehabilitation facility who attended a continuing education course on strategies for handling challenging behaviors. Data were collected from therapists at three time points: before (n = 44) and after (n = 30) the course and at 12-wk follow-up (n = 25). Surveys assessed knowledge of behavioral principles, feasibility of behavioral intervention, strategies used to address behaviors, frequency and types of behaviors observed, and therapists’ perceptions of behavioral impact on participation and outcomes. Quantitative data were analyzed descriptively and using nonparametric Wilcoxon signed rank test because of unequal sample size. Open-ended questions were examined qualitatively using thematic analysis.

RESULTS: Challenging behaviors were identified by all survey respondents in all three surveys. Frequent behaviors reported were temper tantrums (70%), impulsivity (52%), and inattention (48%). Participants demonstrated increased knowledge (p = .003) and acceptance (p = .003) of behavior principles immediately after the course. Knowledge at follow-up was retained; however, acceptance decreased significantly (p = .048). Other factors examining behavioral strategies in rehabilitation (e.g., feasibility, system climate) also increased after the course but returned to baseline levels at follow-up.

Overall, participants reported similar reasons across surveys as to why a child engages in challenging behaviors: to communicate, to avoid tasks, or in response to a difficult task. All reported observing the impact of challenging behaviors on participation and outcomes at least some of the time. Participants identified these behaviors as leading to reduced demands, task changes, and lessened expectations, resulting in less time to address outcomes, disruption of therapy, and decreased participation. Additionally, participants reported they would attempt to implement behavioral strategies to shape appropriate behaviors, yet they had returned to familiar, nonbehavioral strategies at follow-up.

CONCLUSION: Survey findings suggest that challenging behaviors are prevalent in rehabilitation and have a considerable impact on participation and achievement of outcomes. Participants retained knowledge of behavior strategies but did not report implementing new principles consistently. By incorporating behavioral principles into therapy practice, challenging behaviors can be identified and addressed quickly with less disruption to the therapeutic process.

IMPACT STATEMENT: This study contributes to pediatric rehabilitation by identifying challenging behaviors as barrier to successful participation in therapy. This research can inform future intervention that targets challenging behaviors by identifying types of behaviors and reasons why children demonstrate behaviors that decrease participation in therapy.

References

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