Risa Nakase-Richardson, Ph.D. James A. Haley VAMC Polytrauma Program Tampa, Florida

1. Using the ABC Approach to Inform Treatment: Behavioral Assessment of Challenging Behaviors After TBI Risa Nakase-Richardson, Ph.D. James A. Haley VAMC Polytrauma Program Tampa, Florida

2. Talk Objectives • Participant will: • Identify and define 3 components of functional analysis used in behavioral assessment • Demonstrate application of functional analysis to a brain injury case vignette • Identify team, family, and patient considerations when implementing behavior management after brain injury

3. GOAL of Talk • Understand perspective of behavioral specialist so that you can facilitate and maximize the intervention • Provide some examples to practice preliminary functional analysis • Global recommendations about working with behavior management issues

4. RELAX! • Learn to control your own emotions • Check value statements/behaviors at the door • Use relaxation technique to help you in stressful situations • Deep Breathing • Guided Imagery • Exercise/Time to self

5. Orientation Alertness Focusing Attention Speed of Processing Remembering New Info Remembering Past Info Perception of Environment Expressive language Receptive language Fatigue Executive Skills Reasoning Sequencing Multi-tasking Behavioral Control (start, stop, & resisting impulse) Emotional Control (inappropriate or intensity change) Examples of Cognitive and Behavioral Changes After ABI / TBI

6. What is Functional Analysis? Assessment process for gathering information to inform treatment • Interview • Direct observation over time • Systematic manipulations

7. Functional AnalysisABC Model “A” Antecedents “B” Behavior “C” Consequences

8. ABC Model: “B” Behavior “B” Behavior • Describe the behavior • What does it look like? • Frequency • Duration • Intensity

9. ABC Model: “A” Behavior B “A” Antecedent • What factors preceded the behavior? • People • Places • Objects • Time of day • Activities occurring

10. Antecedents are Predictors • Important to identify when behavior will occur • Anticipate and possibly PREVENT problem behavior • Examples • Agitation due to sleep deprivation (possibly reschedule their down time. • Agitation due to lack of comprehension of situation. • Agitation due to motor restlessness associated with post traumatic amnesia/confusion.

11. ABC Model: “C” Behavior A B “C” Consequences • What happened? • How did people react? • What did the person get? • What did the person avoid? • What else changed?

12. Consequences (Learning & Maintaining) • Consequences can cause learning of a problem behavior • Consequences can maintain/perpetuate a problem behavior • Consequences that start a problem behavior may not be what “maintains” it over time

13. REINFORCERS Anything given or taken away that increases likelihood a behavior will occur again Person specific Situation specific PUNISHERS Anything given or taken away that decreases likelihood of a behavior occurring again. Person specific Situation specific Examining ConsequencesWhy it occurs?

14. Functional AnalysisABC Model Summary “A” Antecedents “B” Behavior “C” Consequences • For example: • People (+ or –) • Places • Things • Events • Time of Day • All things occurring • as a result of “B” • What happened • Reaction from others • Get something • Avoid something • Other changes • Describe: • Looks like • Frequency • Duration • Intensity

15. Context of Behavior Problem(Ecological Factors) Aspects of a person’s environment that do not happen immediately before or just after problem behavior but still have an effect on the behavior. Diagnosis Stage of Illness Sleep Cycle Diet Changes Medications Daily Schedule

16. Behavioral Treatment • 1)Conduct functional analysis / A B C • 2) Predict: When and Why • 3) Test hypothesis and continue monitoring • 4) Evaluate intervention and modify if necessary • 5) Re-test hypothesis or go to hypothesis #2 • 6) Evaluate intervention (collect data)

17. Idiographic not Nomothetic Approach • Each behavioral intervention is different /unique to the person and the function of the behavior (idiographic). • There is no one behavioral treatment method (nomothetic) for dealing with all problem behaviors.

18. Important Point! Behaviors with similar topography (appearance) can have different functions across different situations. • Examples • Agitation due to sleep deprivation (possibly reschedule their down time. • Agitation due to lack of comprehension of situation. • Agitation due to motor restlessness associated with post traumatic amnesia/confusion.

19. Team Considerations • Be consistent • Don’t expect quick fix • Everything is relative • Educate yourself about course of illness • Educate yourself about pt impairments • Monitor behavior • Communicate with everyone • Challenges • Debrief with Psychologist/Neuropsychologist • Burnout Issues

20. Patient Considerations • Don’t talk down to patient • Focus on behavior not person • Undesireable behavior not Undesireable person • Monitor your own response (emotions, behavior) • Explain course of illness and do so repeatedly if necessary (e.g., memory impairment)

21. Family Considerations • Educate • Family conferences • Regular meetings • Embarassment factor • ID and intervene with ineffective coping strategies • Explain importance of consistency • Generalizability Issues

22. Functional AnalysisCASES “A” Antecedents “B” Behavior “C” Consequences • For example: • People (+ or –) • Places • Things • Events • Time of Day • All things occurring • as a result of “B” • What happened • Reaction from others • Get something • Avoid something • Other changes • Describe: • Looks like • Frequency • Duration • Intensity

23. Staff Considerations to Maximize Appropriate Responding and Participation

24. Functional AnalysisABC Model Summary “A” Antecedents “B” Behavior “C” Consequences • For example: • People (+ or –) • Places • Things • Events • Time of Day • All things occurring • as a result of “B” • What happened • Reaction from others • Get something • Avoid something • Other changes • Describe: • Looks like • Frequency • Duration • Intensity

25. Case 1: Background: • Background: Patient is a 17-year old male status post severe TBI from ATV accident 5 months earlier. Neuro-imaging revealed diffuse injury. He was nonverbal at the time of evaluation but could point to yes/no card to answer simple questions. When orientation was assessed this way, he was disoriented except to name and hometown. He was also dependent in all aspects of self care but was able to use his left hand to do gross motor tasks such as holding cones in occupational therapy. He was tall and muscular and required a two-person assist with all transfers. His parents were supportive and present throughout the day to accompany their son during all therapies and aspects of his medical care. • Complaint: During behavioral management rounds, the patient’s OT and PT complained that the patient needed medication. They reported that the patient grabbed their breasts and buttocks during therapies. The SLP did not have this complaint.. Therapists also complained that the parents “just stood there” and did nothing to assist them in these moments. Later interview with nursing revealed inappropriate touching (during transfers). Psychologist First Observation/Data Gathering Session: Patient observed in joint physical and occupational co-therapy session. The patient was noted to attempt grabbing behavior only when working in close proximity (most of the time due to his physical status) to his young, female therapists.

26. ABC Model: “B” Behavior “B” Behavior • Describe the behavior • What does it look like? • Frequency • Duration • Intensity

27. ABC Model: “B” Behavior B “A” Antecedent • OT & PT sessions close proximity). • When female staff were on his left side • Grab some of the female nurses during transfers. • Never grabbed mom, dad, or other male staff.

28. ABC Model: “C” Behavior A B “C” Consequences • No reaction from parents • PT/OT embarrassed (flushed, nervous laughter) • Told patient “no” (while laughing) • Session continued.

29. Hypothesis 1: • Patient is showing disinhibition (poor impulse control) when presented with stimuli of sexual nature. He only grabs when in close proximity. • This is occurring in his two therapies in which he has close contact with OT & PT. Not happening in SLP because he sits at a desk when working with SLP. • He reportedly has engaged in this behavior with female nursing staff during transfers (close proximity). • Persons with severe TBI can exhibit poor behavioral control that is expressed with sexual gestures (verbal and nonverbal). • This clinician’s experience is that it is common among young male TBI survivors and that it fades during the recovery process (typically in the first year) sometimes longer with the exception of two cases in 10 years (for another discussion).

30. Treatment approach:Educate, Educate, Educate • Involve and educate family about this symptom. • Inform therapists that family were embarrassed and had no idea what to do in this situation. They were hoping the therapists would guide them in responding to the behavior. • Educatethat this behavior can be common and has nothing to do with who the patient was before his injury . • This is likely a transient symptom of his neurological injury (i.e., poor impulse control, environmental dependency, or suspected hypersexuality).

31. Treatment approach:Prevention Strategies First! • Adopt response prevention strategies. Antecedents are female staff in close proximity to his left side (good side). • Plan to ask dad to hold patient’s left hand in “high risk” situations. • Teach dad (male) to do transfers at bedside. • General strategy was to have patient use his left hand in activities that were incompatible with grabbing of female staff (i.e., holding dad’s hand; holding therapy devices, etc.).

32. Treatment approach:Consequences/Redirection • If the behavior was to occur, involve dad or mom in responding to the behavior in a “parental” tone of voice as a consequence and redirect patient to appropriate therapeutic tasks. • Ask therapists to not laugh or display behavior that could be perceived as reinforcing (he may have enjoyed that he made them laugh – even thought it was a nervous laugh). • Have them also make a firm “no” response at conversational volume and redirect patient to therapeutic activities.

33. Results: • Hypothesis 1 worked! • Highlighting the importance of identifying antecedents, we prevented the behavior a majority of the time by • having patient engage in a behavior incompatible with grabbing during high risk situations in therapy. • Dad or male nursing staff handled all transfers throughout the day. • Collectively, these are response prevention techniques since we prevented the behavior by accurate identification of antecedents. • Over time, the TBI patient’s symptoms faded and inappropriate grabbing was no longer an issue.

34. Attention/Memory Impairments Treatment Considerations • Consider length of treatment sessions • Shorter sessions; more frequent sessions? • Consider length of tasks within a session • Utilize distraction free environment • Minimize over-stimulation • Monitor closely to keep on task (1:1)

35. Treatment Considerations - Continued Abbreviated Instructions (simple and short) Minimize multi-tasking in an assignment or strategy. Use external cues to drive or initiate behavior (poor self-cueing for strategies) Relevant or interesting tasks may keep attention longer than irrelevant tasks

36. Anosognosia / Memory Treatment Considerations Set clear goals for treatment tasks and indicate relevance for patient & family When giving choices, be clear, concise, and limit the number of options Provide immediate feedback to correctness or appropriateness of responses

37. Inattention/Neglect Treatment Considerations Realize that information presented to left side may not be heard or seen Present to right side Note that right neglect occurs too Complex visual information may be poorly perceived (home activities with pictures; written material).