Behavioral Impairment: Recognition and Management

Jennifer Bogner and Tracy Shannon

GENERAL PRINCIPLES

Definition

Deficits in behavioral regulation are often observed following moderate-to-severe traumatic brain injury (TBI). The following are among the more common behavioral sequelae:

• Agitation: “An excess of one or more behaviors that occurs during an altered state of consciousness” [1]. Any excessive behavior can be classified as agitation, including but not limited to behaviors associated with restlessness, lability, disinhibition, or aggression. Agitation is observed in people with a range of disorders who experience an altered state of consciousness; following TBI, agitation is observed during posttraumatic amnesia/confusion.

• Irritability, anger, and aggression: Irritability is used to describe both the internal state (i.e., easily aggravated) and the external state (i.e., verbal or physical expressions of anger) [2]. Aggression may be verbal or physical, and can be directed toward persons or objects.

• Impulsivity and disinhibition: These terms are often used interchangeably to describe the tendency to act (or speak) without taking into consideration alternative actions or consequences. These behaviors often run counter to social conventions.

• Sexually intrusive behavior: Disinhibition can be manifested as intrusive, sexually oriented speech or behavior that is not in line with the context, relationship, or social conventions.

• Lack of initiation: Difficulties with starting an action despite desire to do so. Sometimes, initiation problems are associated with deficits in sequencing.

Epidemiology

• Approximately one-quarter to one-third of patients receiving inpatient TBI rehabilitation in the U.S. display agitation during their stays [3–5].

• Reports of the incidence or prevalence of postacute challenging behaviors have been wide ranging due to differences in definitions and settings. A review of referrals to a behavior consult service suggested that 90% of challenging behaviors fall into approximately nine categories, including: physical aggression, verbal aggression, aggression toward self, aggression toward objects, sexually inappropriate/disinhibited behavior, socially inappropriate behavior, repetitive behavior, lack of initiation, and wandering behavior [6]. In their assessment of 514 community-based rehabilitation patients in Australia, Sabez et al. [7] reported a challenging behavior prevalence rate of approximately 54% within their sample. Aggression, inappropriate social behavior, and lack of initiation were the three most common types of challenging behaviors reported.

Etiology and Pathophysiology

Following TBI many individuals exhibit new maladaptive behaviors that either did not exist prior to the injury or are exacerbated. While the environment, co-occurring disorders, and other person-related factors can contribute to the behavioral presentation, damage to the frontal and temporal regions is also thought to underlie many of the changes observed [8]. For example, the orbitofrontal cortex has been frequently implicated as a mediator of self-regulation—the ability to make choices and execute behaviors that are consistent with one’s goals and values [9,10]. Damage to this area is often manifested as disinhibition and a tendency to act impulsively without regard to future consequences [11,12].

DIAGNOSIS

Risk Factors

• Agitation is associated with lower cognitive functioning, and the presence of factors that might decrease one’s abilities to use cognitive and executive functions (e.g., medications that suppress cognition, presence of infection) [3]. Otherwise, attempts to predict agitation have met with limited success.

• Predictors of aggression include age of onset (younger age at time of injury is associated with higher risk of developing aggression) and communication deficits [13,14]. Additionally, Baguley et al. [14] found that individuals who demonstrated aggression were also likely to endorse depression.

Clinical Presentation

• Initially following injury, individuals may demonstrate periods of agitation associated with posttraumatic confusion. Agitation is characterized by a range of excessive behaviors that can be exacerbated by internal (e.g., disorientation, pain) and external (e.g., overstimulation) triggers.

• As an individual progresses through the initial stages of recovery and orientation improves, difficulties with agitation often decrease; however, more specific problems with behavioral regulation can emerge [15]. (See Chapter 55 for a more detailed discussion of this topic.)

• Management of acute agitation and long-term behavioral consequences associated with TBI is necessary to assist with treatment engagement, maintain patient and caregiver safety, and maximize the rehabilitation process and outcomes [16–18].

Assessment

The assessment method should be chosen based on the nature of the target behavior(s). Rating scales have utility when the target is a cluster of behaviors that characterize one construct, such as agitation or irritability. If the target is a more specific behavior, such as physical aggression toward others, then functional behavioral analysis (FBA) will be more effective.

Rating Scales

Rating scales used to evaluate the effectiveness of interventions should provide more information than simply the presence or absence of the behavioral construct. The severity, frequency, and/or intensity should be measured serially on a continuous scale to evaluate changes from baseline to postintervention. Numerous rating scales have been developed for clinical and research purposes [19]. The few outlined here are those that have been frequently used to monitor the effectiveness of behavioral interventions.

• Given that agitation is comprised of a complex of excessive behaviors that can range in intensity, the agitated behavior scale (ABS) [20] was developed to provide a method for quantifying the intensity of agitation by the extent that it interferes with functional activities. The ABS allows for serial assessments of agitation across observational periods (e.g., shifts, therapy sessions). The 14 behavioral items are rated on a scale of 1 through 4, with higher ratings indicating greater interference with functional activity and decreased responsiveness to redirection. The psychometrics of the ABS have been well established, indicating sound inter-rater reliability, internal consistency, concurrent validity, and construct validity [20–23]. Rating scale and factor analyses indicated that agitation as measured by the ABS is best represented as a unitary construct, though three correlated factors are present that may provide important clinical information (aggression, disinhibition, lability) [21,23].

• The neuropsychiatric inventory (NPI) [24] was originally developed to evaluate behavioral disorders in persons with dementia. However, it has recently come into increased use with multiple neurological diagnoses, including TBI, as a means for assessing the effects of interventions on a range of psychiatric and behavioral disorders (e.g., thought disorders, agitation and aggression, irritability, disinhibition, depressed mood). Informants report on the presence, severity, and frequency of behaviors. Reliability, content, and concurrent validity have been established. Reports have been mixed regarding responsiveness to change [25].

• The Overt Aggression Scale [26] is an observational scale involving the rating of aggressive behavior and the interventions that follow. It was adapted for use in neurorehabilitation settings by adding the ability to record information about antecedents as well as expanding information on interventions [27]. The scale provides information similar to that obtained using applied behavioral analysis (ABA) observational techniques. The measure has been used to report on the prevalence of aggressive behaviors as well as on the effectiveness of interventions [19,26–28].

Functional Behavior Analysis

For the promotion of adaptive behaviors and management of maladaptive behavior in the postacute stages of recovery, one needs to gain an understanding of the factors that influence current behavior through an FBA.

• FBA assists with informing the behavior treatment plan as it allows the treatment team to form interventions that specifically target the behavior [29–31]. Specifically, understanding the function of the individual’s behavior (e.g., task avoidance, social reinforcement, self-stimulation) and identifying the context when the behavior emerges allows for a more efficacious treatment plan. Furthermore, continued data collection to assess the individuals’ response to the intervention (e.g., decrease in frequency, intensity) is necessary, as modification to the plan may be needed.

• FBA methods differ slightly depending on whether the approach is ABA or positive behavior interventions and supports (PBISs) (see “Treatment” section for details on these methods) [32]. ABA utilizes a controlled environment which simulates potential conditions in the natural environment (usually four conditions: social negative reinforcement [task avoidance]; social positive reinforcement [attention, tangible items]; automatic reinforcement [self-stimulation]; and a control condition [access to play or preferred stimuli] condition) [27–29]. PBIS functional analysis occurs within the natural environment, focusing on internal states and environmental factors that contribute to or impede positive behaviors [32]. For both approaches, once the function(s) of the behavior has been determined, an intervention can then be selected and a behavior plan implemented.

Adjunctive Assessments

In addition to measuring the target behaviors directly, assessments of functions and factors that can underlie the behavior or be affected by the intervention should also be conducted. FBA will often naturally incorporate these assessments. Rating scales of behavior should be accompanied by serial assessments of cognition and level of confusion, pain, sleep, and any other patient-specific factors that may either be influencing the behavior or may be impacted by the intervention.

TREATMENT

Guiding Principles

• Antecedent management can help foster positive behaviors and minimize maladaptive, undesired behaviors. The control of antecedents (both internal and external, recent as well as remote) is required to facilitate positive behaviors in general [32]. Internal events can include the individual’s sense of subjective well-being, level of physical discomfort, and clarity of thinking, among other factors, which can influence how the person is able to respond in accordance with goals and environmental demands. Ideally, the environment should facilitate positive behaviors by increasing the individual’s ability to successfully meet demands. Environmental management of external triggers and barriers to positive behaviors is essential to shaping behavior, especially for those who are unable to self-monitor [33]. When manipulating the environment the goal is to “establish external, situation and contextual influences on behavior” in order to shape behavior without placing an increased demand on the patient [15]. Individuals are more likely to respond with aggression or other challenging behaviors when they are confused, afraid, or are being asked to complete a task that is beyond their abilities. Provide a highly structured and consistent routine to assist with reducing these factors [15].

• Identifying triggers or signs of behavior escalation is also important (e.g., does the person appear to be tensing his or her muscles, breathing more heavily, does his or her face appear flushed). If such signs are identified early, redirection/distraction or a brief break may prevent a challenging behavior from emerging [15]. Additionally, if the challenging behavior is prevented, this can allow positive reinforcement for prosocial behavior (e.g., praising the individual for “walking away” when he or she needed a brake).

• The consequences that follow the behavior can influence whether the behavior will occur again in the future. Just as a challenging behavior is often a form of communication (e.g., I want your attention, this is too hard for me) it can also be maintained or extinguished by the caregiver or treatment team’s response. Subsequently, identifying contingencies that maintain behavior and consequences that appear to reduce behavior often inform the treatment process. For example, if an individual engages in a challenging behavior in order to gain attention, attending to prosocial behaviors and ignoring the challenging behavior (if the behavior does not place an individual at substantial risk) is recommended. In contrast, if an individual engages in a challenging behavior in order to escape from the task demand, structuring the task demands such that demands decrease only with prosocial behavior will be more effective.

• Treatment should, at best, enhance cognitive functioning; at worst, treatment should have no effect on cognition. Deficits in cognitive and executive functioning are thought to often underlie agitation as well as later-occurring behavioral impairments. Based on this premise, treatment should work to maximize orientation and cognition, or at the minimum, not have any deleterious effects. This guiding principle is most applicable to pharmacologic treatments that can vary according to whether they work to enhance cognition versus suppress behavior through sedation. Animal studies have demonstrated that the use of antipsychotic agents to suppress behavior at the expense of cognition has a negative impact on short- and long-term outcomes [34]. Human studies have been more limited and often based on observational rather than experimental designs; however, they also lend support to the need to carefully assess the positive and negative effects of a pharmacologic intervention on cognition, due to the potential impact on both short- and long-term outcomes [3,4,35,36]. For example, the use of antipsychotic agents or benzodiazepines to control agitation may suppress cognition and increase sedation, which can not only have a paradoxical effect on the behavior but can also impact short- and long-term outcomes [35].

In addition to considering pharmacologic agents that enhance rather than suppress cognition, treatment should focus on other internal factors that can impact cognition. Studies of small clinical samples have indicated that stabilization of the sleep/wake cycle is needed for improvement in cognition and agitation [37]. It has also been recommended that treatment of underlying disorders than can increase discomfort or confusion (e.g., infections, respiratory distress, constipation) be one of the first considerations for reducing agitation [3,38]. If changes in behavior occur rapidly, additional laboratory studies and radiographic assessment may be recommended to rule out metabolic disturbance, infections process, emergence of a new hemorrhage, and so on.

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