Fig. 1
Median confidence in modifying treatment services for patients with disorders
Fig. 2
Percent of sample indicating type of behavior management education
Below, we highlight some of the critical elements of the intervention, present case studies to rehearse concepts presented, and summarize with a conceptual framework of elements critical to understanding behavioral issues after TBI. These elements can be delivered in formal workshops on BME to facilitate caregiver understanding of working with this complex patient group. We welcome you to reproduce these materials for your own use.
Introduction to Functional Analyses
What is Functional Analysis?
Many resources exist for reviewing common problems and behavior management recommendations following brain injury; however, one of the most critical components to effective behavioral interventions is implementation of functional analysis prior to an intervention [52, 53]. Functional analysis establishes the function of a behavior by examining the “three-term contingency” (i.e., ABC) model (see Table 1).
Table 1
Three term contingency model (ABC)
A | The antecedents to a problem behavior | What are the people, places, events, time of day occurring immediately before the behavior? |
B | The actual problem behavior itself | What does the behavior look like (topography)? |
What is the frequency duration intensity? | ||
C | The consequences are the things that immediately follow a behavior occurring (that may or may not influence the likelihood of recurrence) | What happened immediately after the behavior occurred. How did people react? |
What did the person get (good or bad)? What did the person avoid (good or bad)? What else changed? |
An individualized approach to behavior management includes conducting functional analysis to identify the problem behavior, antecedents, and consequences [52, 53]. Functional analysis uses both direct observation and interviews with staff, family, and possibly patients. Once the problem behavior is defined, antecedents and consequences are identified. A hypothesis may be generated from the data gathered that potentially predicts when the behavior may occur (triggers) and why (consequences) that facilitate a behavior management recommendation. Once the triggers are identified, a response prevention approach is recommended rather than a “reactionary” approach. Behavior management interventions that focus solely on implementing consequences when a problem behavior occurs are often more time-consuming and stressful than prevention strategies. By preventing the problem behavior from occurring in the first place, patient, family, and staff benefit from a less stressful rehabilitation experience. An approach may look as follows:
1.
Conduct functional analysis/A, B, C (using interview and observational data)
2.
Predict: when and why
3.
Test hypothesis and continue monitoring
4.
Evaluate intervention and modify if necessary (collect data)
5.
Retest hypothesis or go to hypothesis #2
6.
Evaluate intervention (collect data)
To facilitate rehearsal of the functional analyses technique, we feel it is critical to implement it with actual case vignettes. Recipients of our workshop series have repeatedly stated that applying functional analyses to cases (behavioral rehearsal) had greatly facilitated learning the concepts. Prior to practicing with cases, we want to discuss some other behavior management constructs that are often misunderstood.
Consequences that facilitate learning of behaviors are categorized into reinforcement and punishment (see Table 2 for basic definitions) [52, 53]. Although each of these techniques could have several chapters written about them, we will simplify this section by focusing on these two global constructs. Simply put, effective reinforcement increases behavior and effective punishment decreases it [52, 53]. Key to these constructs is figuring out what is effective for each person. In our experience, lay persons equate reinforcement with giving food, going on passes, and receiving some form of praise, without realizing that reinforcers vary by person. What is reinforcing for one patient may not be for another. Further, untrained persons may be less skilled in deconstructing problem situations where subtle reinforcement is involved in why a problem behavior occurred in the first place (as highlighted in case vignettes 1–2). Similarly, punishment is often construed as taking away of privileges or verbal rebuke. This may or may not be meaningful to all patients. Lay persons are less aware of how staff responses such as “ignoring” an inappropriate behavior, a technique known as withdrawal of reinforcement, can decrease likelihood of it occurring again. This is illustrated in Case 2. As we progress through the case vignettes, it will be important to understand the basic definition of reinforcement and punishment as we analyze the consequences of the behavior problems (see Table 2). The cases are actual behavior management consultations received during inpatient behavior management rounds or inpatient staffing reports. The details of the cases have been changed to protect the privacy of patients, family, and staff. As you read the cases, you may make use of the worksheet in the Appendix to practice recording antecedents, behaviors, and consequences of the problem scenarios.
Table 2
Contingency management techniques
Technique | Definition |
|---|---|
Reinforcement | Anything that increases the likelihood that the behavior will occur again |
Punishment | Anything that decrease the likelihood that the behavior will occur again |
Behavior Management Rounds Case 1
Complaint
During behavioral management rounds, the patient’s occupational therapist (OT) and physical therapist (PT) (both females) suggested that a particular patient needed medication to control his behavior. They reported that the patient grabbed their breasts and buttocks during therapies. The speech language pathologist (SLP) attending rounds did not have this complaint. Nursing was not present and had not voiced this concern previously. Therapists also complained that the parents “just stood there” and did nothing to assist them in these moments.
Background
Patient was a 17-year-old male status post-severe TBI from an All-Terrain Vehicle accident 5 months earlier. He arrived for comprehensive rehabilitation at 3.5 months post-injury because of the severity of his TBI. He initially presented minimally conscious with episodes of dysautonomia requiring sedating medications to manage. Review of neuroimaging revealed diffuse axonal injury in bilateral frontal lobes, temporal lobes, and parietal lobes. Although he was nonverbal at the time of evaluation, he could point to yes/no cards to answer simple questions, which was a significant improvement in his responsiveness. When orientation was assessed this way, he was oriented to name and hometown only. He used a wheel chair for ambulation but was dependent in locomotion. 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. Because his left hand was his only good arm, he also used it to point to yes/no visual cards. He was tall and large, requiring 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.
Psychologist’s First Observation/Data Gathering Session
The patient was observed in a joint physical and occupational co-therapy session. The patient was noted to attempt grabbing behavior with his left hand only when working in close proximity (most of the time due to his physical status) to his young, female therapists. This commonly occurred when working on sitting balance on the mat in the gym. When the patient grabbed his PT, she verbalized “No, you shouldn’t do that.” She appeared to be embarrassed which resulted in nervous laughter during her redirection of the patient. The parents were present but did not respond to his inappropriate behavior. Subsequent interview with the family revealed that they were embarrassed, but did not know how to intervene. They were eager to assist but wanted to avoid interrupting the therapy session and thought that the therapists knew how to manage the behavior. They reassured the psychologist that the patient was raised in a Christian home and did not act this way before. Both mother and father denied inappropriate sexual behavior directed at them; however, the mother reported that she thought she had walked into his hospital room while the patient was touching himself with his left hand. Nursing staff subsequently reported that the male patient would occasionally grab them when assisting with transfers. During interviews and direct observation, it was noted that the behavior only occurred with female staff. He never attempted to inappropriately grab male hospital staff.
Results of Functional Analyses
Define Problem Behavior
Inappropriate sexual behaviors: grabbing of PT/OT breasts and buttocks
Duration: persists until patient redirected or the stimulus (person) is further away from the patient
Antecedents
OT and PT sessions during therapeutic exercises (sitting balance—using arm to grab cones, transfers, and other times when therapists were in close proximity)
When female staff were on his left side with reach of his left arm
Upon interview with nursing staff, he would reportedly grab some of the female nurses during transfers
Consequences
No overt reaction from parents.
Therapists showed embarrassment (flushed face, nervous laughter), and told patient “no” in casual voice and continued with sessions.
Hypothesis
Patient is showing dis-inhibition (poor impulse control) when presented with stimuli of sexual nature. His limited motor control allows him to grab when in close proximity. This is occurring in his two therapies in which he has close contact with OT and PT. It is 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). The response may represent a form of environmental dependency in which he reacts to stimuli without conscious awareness that he is doing so. These cognitive-behavioral impairments are observed following frontal lobe injury consistent with this patient’s history. It is our clinical experience that this behavior can occur among young male TBI survivors and that it commonly resolves during the recovery process.
Treatment Approach
1.
We involved and educated the family about this symptom. We informed 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. We discussed with both therapists and family that this behavior can be common and has nothing to do with who the patient was before his injury. We highlighted that it is likely a transient symptom of his neurological injury (i.e., poor impulse control and possible hypersexuality).
2.
To facilitate managing this behavior, we adopted response prevention strategies. Since the antecedents were female staff in close proximity to his left side (good side), we asked dad to hold the patient’s left hand when not being therapeutically addressed in “high risk” situations. We also recommended that the 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.).
3.
If the behavior occurred, we planned to involve dad or mom in responding to the behavior in a “firm” tone of voice and redirecting the patient to appropriate therapeutic tasks. Caution was taken to avoid embarrassing the patient in front of others.
4.
We asked therapists not to laugh or display behavior that could be perceived as reinforcing (he may have enjoyed that he made them laugh—even though it was a nervous laugh). We asked them to rehearse a firm “no” response and redirect patient to therapeutic activities while avoiding embarrassing the patient (which could escalate a situation).
5.
We also asked staff to facilitate teaching the patient’s father how to transfer him at bedside since he was present every day. This allowed female nursing staff to have an additional male person to assist with transfers. Dad was often on the left side.
Results
The strategy was effective, highlighting the importance of identifying antecedents, we prevented the behavior a majority of the time by having the patient engage in a behavior incompatible with grabbing. Dad or male nursing staff handled all transfers throughout the day. Collectively, these served as response prevention techniques, since we prevented the behavior by accurately identifying antecedents. Over the next month, the patient improved neurologically, including improved orientation. As he improved neurologically, the inappropriate grabbing was no longer an issue.
Behavior Management Rounds Case 2
Complaint
PT and OT reported that a patient attempted to strike them several times with his fists. He had significantly injured one of the OT technicians and she was placed on medical leave due to injury to her hand. Nursing reported similar problems during transfers. The patient would become agitated, but had not hit any of the nursing staff to date.
Background
The patient is a 28-year-old male hospitalized for comprehensive rehabilitation for TBI sustained approximately 2 years earlier. Acute records were unavailable, but follow-up neuroimaging revealed significant encephalomalacia resulting in ventriculomegaly. When discharged from acute hospitalization, he received minimal follow-up for problems such as severe spasticity. He received no PT, OT, or speech therapy (ST) as an outpatient. Most of his days were spent sitting in a wheelchair in front of a television at home. He lived with his family due to his inability to live independently. Upon readmission to rehabilitation, he was found to lack spontaneous speech, but would answer some questions with verbal responses if persistently cued. He was oriented to his name, hometown, and date of birth, but gave his age incorrectly (he gave his age at time of injury). He was disoriented in all other spheres due to severe memory impairments. When asked about his reason for hospitalization, he did not know he was in a hospital and would not provide further responses. When asked about his impairments, he did not acknowledge any deficits including the inability to walk or functionally use his extremities. We felt this patient was unable to develop new memories (anterograde amnesia) which explained his inability to respond accurately to orientation questions and information about his current situation. He also demonstrated significant anosognosia (awareness impairment) which explained his poor understanding of his currently physical and cognitive status. Of note, his family was not present during his rehabilitation stay.
Psychologist’s First Observation/Data Gathering Session
The patient was observed during physical therapy in the main gym. Given the severity of his spasticity, the focal activity was stretching of his legs. During this activity, the patient would attempt to voice “STOP” when stretching began. When he did this, the therapist would respond “we have to stretch your legs.” Patient would again voice “STOP!” The therapist continued to stretch him and the patient subsequently began to swing his arms in an attempt to strike the therapist. The therapist was clearly frustrated and displayed this in her tone of voice. The therapist responded that since he did this, he was not going to get to watch television that evening and he would have to go back to the nursing station immediately and miss therapy at that time as punishment. The patient was immediately brought back to the nursing station and not allowed to watch television that evening.
Results of Functional Analyses
Define Problem Behavior
Hitting/Striking of therapists
Antecedents
PT and OT sessions
Stretching of spastic limbs
Patient yelled “stop”
Therapist ignored patient’s request to stop stretching him
Consequences
Therapist used frustrated tone to react to patient’s behavior
Stopped therapy session and taken to nursing station
No television that evening
Hypothesis
The patient is severely cognitively impaired (poor memory for new information and disoriented) and shows poor awareness for the nature of his deficits and the importance/relevance of therapy activities. Spasticity is a painful medical condition and the focus of his therapies. In order to facilitate further independence with ambulation, this needs to be addressed therapeutically. However, it appears that his perception is that he is being hurt by someone. He wants to stop the painful therapeutic activities when they occur because he does not see the relevance (secondary to anosognosia). Of note, prior to the hitting episode observed, he did engage in a “more appropriate” behavior (i.e., yelling stop) that was “ignored” by his PT.
Patient was never violent with nursing but would yell out loud during transfers. It was suspected that his spasticity resulted in pain during nursing transfers. Since transfers are brief and time-limited activities, the patient did not escalate to violent behavior to stop the painful activity (i.e., transfers) with nursing.
Treatment Approach
1.
We educated his physical therapist about the patient’s cognitive status and poor awareness for his impairments (thus poor understanding of his therapy sessions). We asked the therapist to “remind” the patient of the purpose of his therapy sessions at the start of each session and beginning of new exercises in each session. This facilitated awareness of his physical impairments and relevance of therapy and exercises. Due to his memory impairments, he needed the repeated cues to facilitate remembering why he needed therapy.
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