So often, we, as a group of family members, professionals, and caregivers, find ourselves lost when discussing the management of behavioral needs for people with intellectual disabilities (ID) and dementia. 

We are lost in the abyss of social media “expertise,” while combing through the stacks of professional journals, and running down the rabbit holes of web searches, where we never find solutions to supportthose we seek to help.  

Understand Behavior to Better Understand Dementia     

This article seeks to present an accessible, yet methodological, evidence-based approach to addressing the behavioral needs of individuals with ID and dementia. We will start with the basics of understanding any behavior, by discussing antecedents, behaviors, and consequences.  

We’ll also discuss identifying the function (or cause) of behavior, which allows us to understand, prevent, and manage challenging behavior.  For many, the fundamental approach is to view behavior as a form of communication. However, when a person’s reality changes (e.g., due to dementia progression), understanding what they are communicating becomes inherently more difficult. 

Antecedent, Behavior, Consequence

“The ABCs of Behavior,” which at its most basic, are the antecedent, behavior, and consequence, has an admittedly catchy ring to it – but we need more!  

To start from the beginning, an antecedent is a stimulus that occurs in a person’s environment seconds or minutes before a behavior occurs.  

A behavior is what a person says or does that can be observed or measured.  

Consequences, or better described as the function, are the reason(s) why a person engages in any behavior.  For a quick, yet deeper dive, it is also beneficial to understand that a setting event is a stimulus that occurs hours or days before a behavior occurs.  

Contrary to the components of behavior, all of which occur in the person’s environment (or inside their body), precursor behaviors are actions a person does that precede a behavior (e.g., scowling face, crossing arms, sweating).

For example, Bob has been awake all night and wandering around his home. His mother prompted him to bathe before she left for work, and he went to “his” chair, sat down,  scowled, and crossed his arms.  Upon entering the bathroom with the shower running, he begins to yell, sit on the floor, and hit at his mother. After ten minutes, Bob finally returns to his room where his mother is able to provide a quick rinse with a washcloth, for the fourth day in a row.

Behavioral Analysis Requires Specificity

Identifying the components of a behavioral issue can help determine which parts of the situation need specific solutions. The notion of “we need to change his behavior” is too general.  Rather, we need to think, “what are the components of the behavior and how do we resolve the concerns related to each of these components?”  

For Bob, the setting events are poor sleep and wandering behaviors, whichhappened hours before hisrefusal to bathe. The antecedent was entering the bathroom with the shower running (seconds before the onset of behavior). The behavior was yelling, sitting on the floor, and hitting.  

What were Bob’s precursor behaviors?  Did he do anything indicating he was upset?  Lastly, the consequence, or as we have said, “the function,”has to be identified.  This is the most difficult, but also the most important, dynamic in understanding behavior, as it is how we identify insights, develop solutions, and provide assistance. 

Behavior in Four Domains

The function or reason for any behavior (desired or undesired) includes four domains: access to attention, access to items/activities, escape/avoidance, and sensory functions.  

Access to attention is wanting a social/communicative interaction with another person.   Access to items/activities is generally something tangible or engaging. Escape and avoidance are commonly associated together, but there is a noteworthy difference where escape occurs once an aversive stimulus has been presented and avoidance occurs prior to the onset of the aversive stimulus.  

Sensory functions are related to stimuli that occur within a person and are not always observable, such as pain and cognitive changes. It is important to note that most behaviors are multifunctional, meaning they are increasingly complex. When we have multiple reasons for a behavior occurring, we inherently need multiple solutions! 

When reviewing the example of Bob refusing to bathe, several functions could be occurring at the same time.  

If Bob has been awake and wandering all night, he may be fatigued and less likely to complete daily living tasks in the morning, as he wants to go to sleep (access to an activity).  Walking into the bathroom with the shower running quickly indicates it is time to bathe.  

For a person with dementia, showers can create difficulties with vision (e.g., shadows and depth perception), balance (e.g., falls), changes in sensory feelings (e.g., hot/cold, “stinging” from shower), as well as lesser discussed sensory changes such as proprioception deficits.  

All of these sensory changes could leadBob to want to escape/avoid getting in the shower. Having identified all of these possible functions, we can develop strategies for each, allowing us to adopt an individualized, multi-functional approach that increases the likelihood of the desired behavior of bathing occurring. 

This behavior dissection, if you will, is how behavior analysts work and is a systematic, function-based approach.  It removes the trial and error and “bag of tricks” that are too commonly the foundation of discussions regarding the management of dementia behaviors in people with ID.  

Perhaps most importantly, it also allows for solutions to change with the person over time.  This ability to change and adapt is imperative when working with dementia, given the degenerative and ever-changing nature of the disease progression.

All of Ley’s work is original and no form of AI was used to write this blog. 

Never disregard professional medical advice or delay seeking medical treatment because of something you have read in this article.