Using the A-B-C Behavior Chain
The first step in using an A-B-C Behavior Chain is to collect as much information as possible about difficult behaviors in order to detect patterns about why 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. 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.
After a behavior has been recorded for one week, the chart can be reviewed for patterns among antecedents and consequences. Start by examining the circumstances that precede problematic behavior to come up with reasonable "guesses" about triggers for the behavior. Identifying the triggers is important because you can then work to eliminate them from the environment, or at least try to decrease their impact.
For example, does the person always become aggressive after interacting with a particular family member or service provider? In this case, a specific person may be a source of stress, so the solution may be to limit that individual's contact with the person with dementia.
Does the person with dementia remain calm at home, where it is relatively quiet and peaceful, but engage in wandering when she is in a busy place like the supermarket? In this instance, the behavior may be a way for the person with dementia to decrease anxiety or stimulation in overwhelming settings. Changing this antecedent might involve going to the supermarket at a less busy time of the day, or finding a way for the caregiver to shop alone.
Does the person start moving repetitively when he has to go to the bathroom or has an upset stomach? Here, the function of the behavior is clearly communicating a need. This could be addressed by creating a "bathroom schedule" (i.e., taking the person to the bathroom every couple of hours) or changing the person's diet to something that is easier on the stomach.
Next, examine the chart with an eye for finding patterns in the consequences of the problem behaviors. How do you and other people respond to the difficult behavior? Do you ignore the person when quiet and composed, but pay attention when he or she is agitated? Perhaps the function of the behavior is to gain attention (remember, because the person's brain isn't working properly, he may not be able to ask for positive attention). Here, the solution would be to provide more positive forms of attention (e.g., engaging in pleasant activities together) throughout the day. Or, is arguing actually escalating or increasing agitated behavior? In this case, changing your response to a calm, reassuring one is a good idea.
Be sure to examine the entire environment. If others are involved in the incident, what do they do? If they yell or scold the person with dementia, then changing the consequence would involve teaching others how to remain calm and respond with an encouraging tone.
After the behavior has been tracked and reviewed, the A-B-C Behavior Chain can be used to develop new approaches for dealing with the difficult behavior. The key is to change or adjust the antecedents and/or consequences that might be contributing to the behavior. Remember to change one antecedent or consequence at a time; it is difficult to tell what is working if you change a bunch of things simultaneously. It is also important to be consistent (both you and others who have contact with your loved one). Changing antecedents or consequences only some of the time (and therefore, setting up a chaotic, confusing environment) can actually make the problem worse.
Throughout this process, it is important to remember that people with dementia cannot control or prevent behaviors on their own, because the parts of their brains that allow them to do so are damaged. Caregivers have the ultimate responsibility to change what happens before or after problematic behaviors in order to set up an appropriate environment. It is also important to note that the person's brain is CHANGING (i.e., getting worse), so strategies that work this week may not work forever. Adjusting the environment across time as the person's level of dementia increases is typically necessary.
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 in 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.