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Behavioral Management for Dementia Caregivers Continued

Rudolph C. Hatfield, PhD., edited by Kathryn Patricelli, MA

Using the A-B-C Behavior Chain

The first step in using an A-B-C Behavior Chain is to collect information about difficult behaviors to detect patterns about why or when they occur, or what function they serve for the person with dementia. Caregivers should use a simple chart to record antecedents, behaviors, and consequences for each behavior and should try to be as detailed as possible in the descriptions. The sample chart below can be used to track behaviors. Each challenging behavior should be recorded on a different sheet. Caregivers should fill out the chart as soon as possible after the behavior occurs.

ABC Chain

After a chart for particular behavior has been recorded for one week, the chart can be reviewed. Look for patterns among the antecedents and the consequences associated with the behavior by examining the circumstances that occur before the problematic behavior. Then you can come up with reasonable "guesses" about situations that may lead to the behavior (these are often referred to as triggers). Identifying the triggers is important because sometimes just eliminating them can reduce the behavior or can eliminate the behavior altogether. Trying to change the existing trigger to a trigger that leads to a more positive behavior is the goal. For instance, aggression may often occur in an environment that is very distracting for the person. Eliminating distractions should result in a decrease in aggressive behaviors.

The second step would be to look at the chart for the consequences of the behaviors that you wish to change or eliminate. For example, in the above situation with aggression you could notice that the person with dementia receives all kinds of attention from caregivers when they are aggressive. However, when they are not aggressive they are often left alone. This might be a hint that the person unknowingly becomes aggressive to receive attention. The attention is reinforcing aggressive behaviors. One way to change this would be to pay attention to the person when they are not aggressive and use some form of punishment, such as a timeout, where a person receives no attention when they are acting aggressively.

It is important to understand that using the same approach for everyone may not be successful for everyone. Once the type of behavioral management program is chosen and implemented, caregivers should continue to fill out the chart to see if their new approach is working. This way they can adjust their approach to the person being worked with. Again, it is important to stress that this is not a magical process that automatically makes everything instantly better. It requires attention to detail, adjustments, and understanding that everyone is different (even people with dementia). Caregivers need to find what works with that person. The approach is a general approach that needs to be customized for everyone. It is not up to the person with dementia to change their behavior. It is up to the caregivers to help them change. Additionally, over time people with dementia will become less responsive to many of attempts to change their behavior or to methods that have been successful in the past. This often results in the need to reevaluate the approach and change it.

Example of Using the A-B-C Behavior Chain

Laura is taking care of her mother, Elsa, who has Alzheimer's disease. Lately, Laura has noticed that Elsa becomes extremely agitated during the mid-morning. In the past, Elsa calmly sat in the sunroom each morning and looked at old pictures while Laura worked in her home office. Laura used the A-B-C Behavior Chain to address Elsa's unexplained agitation.

Laura started keeping track of what happened right before and after Elsa's agitated periods. She shifted her routine and worked on her laptop in the kitchen, so she could see Elsa in the sunroom. Laura noticed that around 10 AM each morning, the mail carrier delivered the mail. The mail carrier was a new person - a man who seemed nervous and in a rush - instead of the older female mail carrier that had been coming to their home for years. Laura called the post office and found out that the previous mail carrier had retired and that the new man was her replacement. After some detective work, Laura noticed that as Elsa sat in the sunroom each morning, she could see the nervous, rushed mail carrier as he stomped up to their front door and dropped off the mail. She would become agitated shortly thereafter.

In this situation, an antecedent (the new mail carrier) seemed to be triggering the behavior (agitation). The current consequence was that Laura comforted Elsa and gave her some tea and a snack. This eventually calmed Elsa down, but it did not actually prevent the agitation from occurring in the first place. To address the behavior, Laura eliminated the antecedent/trigger. Rather than having Elsa in the sunroom when the mail carrier arrived, Laura switched the schedule. During that time, Elsa and Laura had tea and a snack in the kitchen. By the time Elsa went back to the sunroom, the mail carrier was already gone. Elsa's morning episodes of agitation decreased when the antecedent was removed.