Working With Challenging Behaviours

(by Linda Thornton)

Most children with PWS have very pleasant, outgoing, cooperative temperaments which remain with them as they grow older. However, they will display challenging behaviours, many of which you will find written about in the literature. Not everyone is the same, but we need to remember that people with PWS face some extra-ordinary challenges in their lives that most of us may never understand.

People with PWS can be very transparent in their behaviours and are quick to display their feelings and emotions. Sometimes these emotions can erupt very quickly and escalate into a full-blown "melt-down" where the person seems to have no control over their actions and the actions can become violent (mostly with things rather than people) and noisy. These might be as a result of something surprisingly little, such as being denied an extra piece of toast at breakfast, or mislaying an object, or being told to do something they may not want to do. Quite often they are incidents that are perceived by the person to be unfair.

The most effective way to deal with challenging behaviours is to prevent them from happening in the first place. The most common identifiable thing that leads to challenging behaviour is anxiety.

There are many strategies used to manage behaviour and very soon we can learn what the triggers are that cause the anxiety which in turn causes the behaviour. The use of praise is one of the best tools you will have - praise for good behaviour (even when you may think it's pretty ordinary) will go a long way in helping stave off 'bad' behaviour, no matter what age the person may be.

There are many characteristics of PWS which makes this syndrome unique and which contribute to behaviours that you may not find elsewhere. Specifically there are several "PWS" behaviours:

  • Food-seeking (including stealing, taking money to buy food, taking food from others, and eating indiscriminately)
  • Temper outbursts (particularly around food, but also around other things)
  • Skin-picking (there is a tendency to a high threshold of pain, but skin-picking also portrays anxiety, boredom, loss of self-esteem, nervousness, and develops into a habit)
  • High pain threshold
  • Temperature dysfunction (often can't tell the difference between hot and cold, and can dress inappropriately for hot or cold days)
  • Obsessive compulsive behaviours
  • Tenuous emotional control

A borderline IQ puts most in the range of mild intellectual ability, but this will be different from person to person and very often there are some extra-ordinary ranges of intellectual ability which may confuse some.

Most people with PWS have a long list of good points as well and may include:

  • Sociable and friendly
  • Good long-term memory skills
  • Receptive language and a good ability to judge others' feelings
  • Good at puzzles and other fine motor skills
  • Helpful, kind, and generous, with a love of little children, babies and animals
  • Good reading skills
  • Good computer skills
  • Often enjoy domestic chores including ironing, washing, as well gardening, mowing lawns, walking and hiking, swimming, horse-riding
  • With support, can easily have a job at their own skill level

Behaviour as a Form of Communication

If we try to look at behaviour as a form of communication - that the person is trying to tell us something that they might not have the verbal ability or comprehension to do so, then we can separate the behaviour from the person and look at what they are trying to say.

All behaviour is a form of communication - it's how we perceive and interpret that behaviour that will lead to success or failure. It's a bit like learning another language.

We all perceive differently, therefore we communicate differently.

When do ‘behaviours' start?

So-called challenging behaviours are not usually around during the first few years of life. Teenage and young adult years are when we generally see the more challenging behaviours. As the person ages into their 30s and older, they are generally less challenging, but can have more medical challenges (read more about this)

Why do we call behaviour "challenging"?

I think it's because we (as parents, or caregivers, siblings, grandparents - anyone, in fact, who is involved with the care of a person with PWS, no matter what the age) find these behaviours as out of the ordinary - they're not ‘normal', they can be embarrassing, we don't understand them, they can be scary and even dangerous and can quickly escalate to a total outburst and meltdown before you can turn around.

Behaviours can quickly escalate from nothing out-of-the-ordinary to verbal outbursts and abuse, physical abuse, crying jags or hissy fits, violence, self-mutilation and trashing.

It can be very scary.

There is a goal for success - it's simple: we need to gain the trust, respect, and bonding of the person in order to reach success. (in fact, that's true for any relationship!)

"Challenging communication" has been described as ‘the emergence of disruptive or destructive behaviours is often the person's way of communicating with an incomprehensible and non-responsive world' (Donellon, Mirenda, Mesaros & Fassbender, p.18.1985)

So, it is learning to interpret the behaviour, as a communication, that is the key. The thing is, we interpret everyone's behaviour according to our own perceptions - whether we like, or dislike a person, what we judge them on, and how they measure up, etc. Well, guess what? People with PWS will also interpret everyone's behaviour, but according, of course, to their own perceptions. And we know that people with PWS have very concrete perceptions! We know that they make up their minds regardless of whether they are right or wrong, we know that they like hierarchy, and we know that once they've interpreted your communication, they will also have judged you, too.

We interpret behaviour by our own social codes; we know how to monitor our behaviours, how to hid our feelings, how to be polite, we understand how to reason, to make allowances, to compromise, to forgive. People with PWS will not have the same social code as you, and their behaviours are often described as manipulative.

I would ask you to think about this word "manipulative". It means, getting what we want , usually by unfair or insidious ways and means. But we have learned several things about the syndrome and how it affects people: We know a person with PWS is very ego-centered, with little ability to "self monitor". We know that their world becomes ‘themselves', we know that most behaviours can be traced back to the hows and whys of food-sourcing. We also know that PWS is a ‘starvation syndrome' and survival for a person means eating.

So - are the behaviours manipulative, or are they just a way of surviving in a world that is contrary and often scary?

If we perceive PWS behaviours as manipulative, then the way we work with them, support them, and respond to them, will be skewed to our perception of being manipulated.

Communication Breakdown

People with PWS like concrete outcomes, they like visual interpretations - something they can see will happen a certain way: a staff member (or teacher) will be there at a certain time, on a certain day, and they will be doing certain things. People with PWS are not good at guesswork, so, if you can, try to make your communications visual, and concrete, so their expectations are not put at variance.

Most "PWS behaviours" that result in a loss of self-control (be it verbal or physical) will have come from a communication breakdown and will have been exacerbated by anxiety. Anxiety, therefore, is the biggest precursor (or clue) to what might happen next. It is the best warning we will get, so learn to recognise what makes your person with PWS, anxious. It can be over little things: when is it going to happen, who will be there, what is expected of me, I can't do this, I don't understand... or it can be over bigger things: "will I get caught? why can't I have more? I hate you - I'm leaving."

Anxiety

We all know what it feels like to be anxious, frustrated, annoyed, or stressed. We know how easy it is for our anxiety levels to rise and for our behaviours to become abrupt, curt, even angry to the point of losing our tempers, saying the wrong thing and often making situations worse. Anxiety, if not controlled, will lead to an escalation in behaviour.

It's just the same, if not more, for people with PWS. Anxiety for them is the inabilitiy to control an already difficult world. We know that they are very ego-centric, that the world revolves around them, so think how easily things can get out of control for them.

Lots of behaviours will increase in intensity and many of these will be easily recognisable:

  • Avoidance or non-compliance
  • Denial
  • Perseveration, muddledness
  • Frustration
  • Argumentative
  • Drop in communication levels
  • Compulsive behaviours

If you see a rise in any of these behaviours, you will know that somewhere along the line there's been a communication breakdown. It's time to wind back the clock and find out what's gone wrong. You can use a variety of strategies:

Avoidance/non-compliance: Give options, and offer to help with the task, or offer alternative solutions and be creative. Check that the task is understood, check the level of abilities around that task, break the task into manageable parts.

Denial: Denial is often used as self-defence (it wasn't me, I didn't do it!) and, quite frankly, there's no point in accusation unless you've caught the person red-handed; just note your suspicions and pass the information on ("I think there was a $10 note taken from my car - please keep a check on any new purchases..."). Don't use open or closed questions and expect an accurate answer - it won't happen. You may choose to ignore the situation rather than engage in argument.

Perseveration/muddledness: Take time to answer fully and check to make sure the person has understood you - get them to tell you what is required of them. Break the task into manageable components. Redirect to one task at a time. Use visual aids if necessary. Put a time limit on questioning. Make sure you have not given the person too many choices - that is a sure way to raise anxiety.

Frustration: Take time to backtrack. Ask simple closed questions (where a yes or no answer will help you quickly understand). Make sure your communication has been understood. Provide good, logical details and reasons and make sure of your facts. People with PWS appreciate being told the full facts rather than a "just because" answer.

Argumentative: You won't win an argument, so don't answer back, no matter how tempting it might be. Take a break, especially if the person is becoming vocal and abusive. Ask if they'd like some time to be on their own. Try to diffuse the situation by asking questions like "tell me what happened so we can try to sort it out". Try to reach a solution or compromise and if necessary, bring in a third person to listen.

Sometimes arguments come completely from left-field, especially when engaged in denial, and then, suddenly, the person with PWS has made themselves the victim and is accusing everyone of not understanding them, of being unfair, and misunderstood. Somehow, when it is perfectly obvious to everyone else that the person with PWS is in the wrong, they have neatly turned the tables on you, and you're the 'bad guy'. This just goes to prove that a concrete outcome has not yet been reached. It's better to leave things for a while, rather than engage in futher argument.

Sometimes you can negotiate a catch phrase that the person feels comfortable with ("this is going nowhere, let's both back down a bit", or "can you find a way to resolve this for me?"). This is a good way of empowering the person to find a way to reach a compromise.

Drop in Communication Levels: This is not a common thing, most people preferring to raise the level of commmunication! However, when it does happen, you will notice the person seeming to withdraw into themselves, maybe start crying. Take a short break, give the person time to collect themselves. Then give them something important to do - a task they might enjoy. Don't insist if they don't want to, but leave the option open.

Compulsive Behaviours: This is sometimes linked with autistic-like behaviours (read more on this) and can present as possessiveness, absolute insistence, accumulation of possessions, repetitive behaviours, may seem irrational. A task that might appear simple, becomes extremely time-consuming and can only be done their way. This might often happen just as you're leaving the house, about to do something, etc. Reasoning might not be possible and sometimes a person needs to learn from their mistakes and if they miss out on an outing, so be it. But make sure you have Plan B!

Blow-outs and Meltdowns: These happen. No matter how well prepared you think you are, how well you think you have your strategies planned, meltdowns and blow-outs happen. You might have missed a precursor, or trigger, missed noticing a communication breakdown, and by the time you've realised it, it's way too late.

During a meltdown, make sure the person is safe, does not have access to sharp tools, breakable objects and so on. Make sure everyone else (including you) is safe. You will have to wait this one through - it will burn out, given time. During the recovery phase, you have only one duty - make sure you do not re-ignite the situation! Stay quiet, give the person space, play quiet music, carry on as though everything were normal. It can be hard to do, but it is the best way to bring a person out of a meltdown. And, please, don't forget - this is the syndrome working here.

When everything has calmed down - maybe the person with PW has had a sleep - you will probably find they will apologise for their behaviour. Nearly every person with PW I have ever met (and there have been many!) apologises and asks forgiveness. Accept the apology quietly. Now is the time to ask if they want to talk about it - if the answer is no, do not persist.

I once asked my daughter what it was like when she was in the middle of a melt-down. Her answer was that there was nothing she could do. It was like a volcano and she had to let it finish itself. She couldn't stop it. I thought that was an interesting insight.

The PWS Association can help with other resources, information, and support around behavioural management. The PWS Association also runs workshops specifically targeted at understanding behaviour in PWS. For more information on these workshops, please contact cindy@pws.org.nz