Collaborative Problem Solving: Can We Expand the Lens to Include Both Children and Individuals with Dementia and Alzheimer's?

An elderly man and a woman in a hat sitting on a stone wall, looking at vineyards.

Parents of children with behavioral challenges may be familiar with two experts in this field: Dr. J. Stuart Ablon and Dr. Ross Greene. Dr. Ablon is the Director of Think:Kids, a program in the Department of Psychiatry at Massachusetts General Hospital (MGH). Dr. Greene is the Founding Director of Lives in the Balance.

I believe that the collaborative problem solving techniques recommended by Ablon and Greene for children could also be used productively by adult children interacting with parents suffering from dementia and Alzheimer's.

I have clear memories of contentious interactions with my Dad. As his dementia progressed, he was extremely resistant to bathing and often didn't want to take his medications. Although the underlying psychiatric and cognitive conditions associated with dementia are certainly different from those experienced by children with challenging behaviors, I think collaborative problem solving frameworks have the potential to build trusting and more harmonious relationships between caregivers and older people.

Who Needs Collaborative Problem Solving?

Both Think:Kids and Lives in the Balance promote the idea that children exhibit challenging behaviors because they don't have the skills needed to adapt to situations and deal with frustration.

This also seems relevant for individuals with dementia and Alzheimer's disease. As their cognitive skills decline, many find it difficult to cope with aspects of daily life that once required little effort or thought. This naturally leads to frustration.

As the Lives in the Balance website notes, an important goal of collaborative problem solving is to "identify the specific conditions or situations in which a challenging behavior is occurring in a particularly challenging child. These unsolved problems tend to be highly predictable."

Think:Kids breaks down skills and potential problem areas for children into five areas. Below I've highlighted examples of skills in each of these categories where I've seen my Dad have problems and I expect other individuals with dementia or Alzheimer's do too:

  1. Executive functioning. Sticks with tasks requiring sustained attention, handles transitions easily, and keeps track of time.

  2. Language processing skills. Is able to tell someone what's bothering him or her, understands spoken directions, and understands and follows conversations.

  3. Emotion regulation skills. Manages irritability or anxiety in an age-appropriate way

  4. Cognitive flexibility skills. Handles deviations from routines and original plans, and handles unpredictability.

  5. Social skills. Pays attention to verbal and nonverbal social cues.

How Does Collaborative Problem Solving Work?

Think:Kids identifies three options for responding to challenging behaviors in children:

  • Plan A. This is the default behavior when adults impose their will and expectations on a child. If conforming to Plan A requires skills that children lack, they may exhibit challenging behavior.

  • Plan B. This forms the core of collaborative problem solving. Adults and children work together to find a solution that satisfies both parties. In most cases, problems require multiple discussions to resolve. However, these conversations strengthen relationships and trust.

  • Plan C. With Plan C, adults put their expectations on the back burner and put a lower priority on them.

Within Plan B, Lives in the Balance identifies three key steps for parents to take:

  1. Empathy. In this stage, the adult gathers information to better understand the child's perspective about the unsolved problem. This includes identifying concerns from their point of view.

  2. Define the Problem. The adult offers information about their perspective on the unsolved problem.

  3. Invitation. The adult and child brainstorm solutions in an effort to develop an action plan that is realistic and that satisfies both parties.

Using Collaborative Problem Solving with Individuals with Dementia and Alzheimer's Disease

I can remember various situations with my Dad when I started out with "Plan A," insisting that he needed to do something that he didn't want to do (such as bathing). There was invariably arguing back and forth. I can't even remember how we reached a resolution in many cases. Yet, we both felt stressed and upset. I'm certain that he was angry that his child was ordering him around, while I wondered why he couldn't just get in the shower like any normal person.

In other instances, I recall resorting to "Plan C." Having a huge battle over something small hardly seemed worth it compared to the other challenges we faced, so I let it go.

Imagine, however, how differently a conversation could go with your elderly parent using collaborative problem solving and Plan B. For example, let's say that my Dad didn't want to take his medications. The three steps of Plan B could be very helpful:

  1. Empathy. I might say to my Dad something like, "I understand that you don't want to take your medication today. Can you tell me why you're feeling that way? Are you worried about something in particular?"  Perhaps he would tell me that he didn't know what the pills were for. That's a reasonable concern and it can be addressed by explaining the medical reason why his doctors prescribed each pill. Or maybe he would say that he had trouble swallowing the pills or that they tasted bitter. Those are both issues that could be addressed by either crushing the pills or perhaps having him take the medication with apple sauce or some other pleasant tasting food.

  2. Define the Problem. In this step, I would explain to my Dad why it was important from my perspective that he take his medications. For instance, I might explain that his anti-coagulant medication is necessary to prevent him from having another stroke. Or that his statin medication is intended to keep his arteries healthy and to avoid a heart attack. I also might add that both he and his health are important to me.

  3. Invitation. If my Dad was still reluctant to take his medications, we could talk together in this stage about possible solutions to the issue. We could discuss cutting up the pills to make them easier to swallow or mixing the medications with easily swallowed foods. Perhaps one option would be to try different approaches for a few days and then regroup to see if the situation was better.

One of the things I like about the collaborative problem solving approach is that it invites dialogue between people. When you are caring for a parent with dementia or Alzheimer's, it can feel like they are no longer really the person that you once knew. What I know from my personal experience, however, is that the essence of the person is still there.

Collaborative problem solving conversations help you maintain the humanity in the relationship with your family member by trying to see situations from their point of view and also sharing your feelings about the situations. As Drs. Ablon and Ross note, it may take more than one conversation. However, I think it's worth widening the lens and giving collaborative problem solving a try as a senior caregiver. I'd be interested to hear how it goes for you!

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