Using the abc approach to inform treatment behavioral assessment of challenging behaviors after tbi
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Risa Nakase-Richardson, Ph.D. James A. Haley VAMC Polytrauma Program Tampa, Florida PowerPoint PPT Presentation


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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. Talk Objectives. Participant will:

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Using the abc approach to inform treatment behavioral assessment of challenging behaviors after tbi

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


Talk objectives

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


Goal of talk

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


Relax

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


Examples of cognitive and behavioral changes after abi tbi

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


What is functional analysis

What is Functional Analysis?

Assessment process for gathering

information to inform treatment

  • Interview

  • Direct observation over time

  • Systematic manipulations


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

Functional AnalysisABC Model

“A”

Antecedents

“B”

Behavior

“C”

Consequences


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

ABC Model: “B” Behavior

“B”

Behavior

  • Describe the behavior

    • What does it look like?

    • Frequency

    • Duration

    • Intensity


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

ABC Model: “A” Behavior

B

“A”

Antecedent

  • What factors preceded the behavior?

    • People

    • Places

    • Objects

    • Time of day

    • Activities occurring


Antecedents are predictors

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.


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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?


Consequences learning maintaining

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


Examining consequences why it occurs

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?


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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.

DiagnosisStage of Illness

Sleep CycleDiet Changes

MedicationsDaily Schedule


Behavioral treatment

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)


Idiographic not nomothetic approach

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.


Important point

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.


Team considerations

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


Patient considerations

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)


Family considerations

Family Considerations

  • Educate

    • Family conferences

    • Regular meetings

  • Embarassment factor

  • ID and intervene with ineffective coping strategies

  • Explain importance of consistency

  • Generalizability Issues


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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


Staff considerations to maximize appropriate responding and participation

Staff Considerations to Maximize Appropriate Responding and Participation


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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


Case 1 background

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.


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

ABC Model: “B” Behavior

“B”

Behavior

  • Describe the behavior

    • What does it look like?

    • Frequency

    • Duration

    • Intensity


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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.


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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.


Hypothesis 1

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).


Treatment approach educate educate educate

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).


Treatment approach prevention strategies first

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.).


Treatment approach consequences redirection

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.


Results

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.


Risa nakase richardson ph d james a haley vamc polytrauma program tampa florida

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)


Treatment considerations continued

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


Anosognosia memory treatment considerations

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


Inattention neglect treatment considerations

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).


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