Behavior Management

1
Behavior Management

• David Krych, MS-CCC-SLP
• ReMed Recovery Care Centers

2
Communication Disorders Associated With TBI

• Pathophysiology of the disorder includes frontal
  lobes, limbic system and connections between said
  structures Ylvisaker et. al 2001
• Discourse described as disoriented, confused,
  stimulus bound, disorganized, reduced in
  initiation, reduced in inhibition. Hagan, C,
  1984

3
Specific Discourse Issues

• Impaired cohesion and coherence, Hartley, 91
  Liles, 89
• Impaired story grammar, Coelho, 95
• Difficulty initiating and maintaining
  conversation, Togher, 97
• Failure to meet the informational needs of the
  listener, McDonald, 93
• Poor topic management, situational
  inappropriateness,
• violation of turn taking, Snow, 1998

4
Psychosocial

• Hibbard, 1998 n 100 patients mean 8 years p.i.
  Depression 61.
• Kruetzer, 2001 n722 patients mean 4 years p.i.
  42 Depression
• Draper et al, 2007 n53 10 years post injury,
  Depression 46, Anxiety 20 and aggressive
  behavior 12.
• Dependent behaviors
• Emotional lability
• Lack of initiation
• Behavioral issues Irritability, Aggression,
  Disinhibition
• Pickelsmire et al, 2007 n 1830 66.5 idd unmet
  need help managing mood, stress and emotional
  upset.

5
Family Status

• Lezak, 1995 80 of individuals w/TBI go through
  divorce or estrangement- 2 yrs post
• Current census data about 50 of all marriages
  end in divorce. Within 3 years 74 remarry.
• Ashley Krych, JROM,vol1,4, 1997
• 74 no change of marital status mean 7 years
  post dc

6
Behavior Is A Continuum
7
Continuum

• Withdrawal to physical aggression It all counts.
  
• Therapists sometimes have rather narrow margins
  of acceptability.
• We want our clients to be normal.
• But normal for what scale?
• This isnt measured on t score tables.

8
How Unwanted Behaviors May Develop

• Predisposition due to cognitive impairment
• A primitive form of communication
• Early displays of unwanted behavior are followed
  by results that are often intended to produce
  comfort or achieve the quick solution

9
How Unwanted Behaviors May Develop, continued

• These results ultimately strengthen unwanted
  behaviors
• Over time this inadvertent strengthening of
  unwanted behavior makes likelihood of recovery
  less favorable and more difficult
• Extinction procedures may also initially produce
  more frequent or intense unwanted behavior

10
Stroke vs. TBI

• Stroke is a discreet event Sequelae are more
  defined and predictable/usually L hemisphere.
• TBI, even minor or moderate injury, represents a
  more diffuse form of injury.
• Coup Contra-coup Diffuse Axonal Injury
• Involvement of Frontal Lobes in TBI is well
  documented Levin, H. 1994
• Right hemisphere damage in stroke is infrequent

11
Frontal Lobes

• Define what we attend to and how that attention
  is manifest. Stuss et all, (2005)
• Rather than a generic functional system,
• Different functions or processes associated
  with different frontal brain regions that have to
  contribute in different ways to perform even a
  very simple task

12
Brain Behavior Relationship

• Still difficult for society at large to
  appreciate the above statement.
• Especially when it comes to right hemisphere and
  frontal lobe behaviors
• This can also be difficult for treaters to truly
  appreciate.
• Changed neurology changed behavior changed
  person.

13
Context

• Behavior does not occur in a vacuum.
• It is contingent and situational.
• What is acceptable in one place is not acceptable
  in another.
• Social rules Most of our expectations come, not
  from our understanding of the BI and Behavior
  Management issues, but from our social
  expectations.

14
Some Things to Leave at the Door

• Our sensitivities
• The box we came in PT, OT, ST etc
• The idea that behavior management is something
  that is done to someone.
• My mood or how I feel today.
• The ghost of therapies past.
• The idea that the psychology department is in the
  business of fixing behavior.

15
Some Things to Remember

• Be patient
• Consistency- within myself and ...
• The team across time
• Inconsistency is worse than no management plan at
  all.
• Commitment to see the plan through and adapt as
  needed.

16
General Guidelines

• Increased rest time - monitor and reduce as
  fatigue lessens.
• Keep the environment simple and predictable
  Beware over stimulation.
• Keep instructions simple Try not to over
  verbalize.
• Set goals and give feed back. Try to do this
  visually as well as verbally.

17
General Guidelines, continued

• 5. Remain calm and redirect to task. Jones and
  McCaughey recommend Gentle teaching
• Ignore off task behavior entirely, redirect
  to task reward. (Bailey 92- some criticism).
• 6. Provide limited choices. (Dyer et.al.92)
  found that clients with choice did better than
  those with no choice or open ended choice.

18
General Guidelines, continued

• 7. Decrease chance of failure (Mace and
  Belifore,90). Work at the 80 level and lead
  with known success.
• 8. Vary activity within consistent skill set.
  Tactics vs. strategy.
• 9. Be over prepared. Remember the clients
  variability. Some days fast some days slow.
• 10. Task analyze Break down tasks. Each step
  can then be treated as a completed task.
  Remember backward and forward chaining.

19
Behavior Plan Format

• Short and long term goals
• Operational definition of target behavior
• Data collection system
• Treatment procedures
• Regardless of the environment there is a
  wide range of competence in carrying out
  behavior treatment programs.

20
Program Components

• Base line
• Choose behaviors to be managed and how it should
  be done Reinforcers?
• Frequency monitors
• Graph over time For staff and client.
• If pharmacology is in the picture be aware of
  impact.

21
Behavior Principles

• Reinforcement
• any consequence that increases the probability of
  a response occurring again
• Two types of Reinforcement
• Positive Reinforcement
• Negative Reinforcement

• Punishment
• any consequence that decreases the probability of
  a response occurring again
• Two types of Punishment
• Positive Punishment
• Negative Punishment

22
Stress Model of The Assault Cycle Smith PART

• Assault is the reaction to extreme stress
• Rehabilitation process is very stressful
• Daily confrontation of deficits sets up a fight
  or flight paradigm. (Remember the continuum)
• Some withdraw some become combative

23
Environmental Model

• Behavior is a product of circumstance within
  which it occurs.
• Expectations
• Level of sound/lighting
• Crowding/over stimulation
• Tone of voice
• Scheduling

24
(No Transcript)
25
Trigger

• Stimulus or event that exceeds the clients
  tolerance for stress (demands for compliance or
  being touched).
• Any techniques for prevention or accommodation
  need to happen before the triggering event.
  (General Guidelines)

26
Escalation

• Increasing levels of agitation or change from
  baseline.
• De-escalation techniques are used at this time.
• The earlier the better

27
De-escalation Techniques

• Active listening begins with eye contact and
  goes to verbal responses of paraphrasing,
  restating and clarification.
• Orientation Gelski et al 95 Disorientation
  shown to be a major contributing factor to
  aggressive behavior in TBI. Use orientation to
  place, time, who is present.
• Redirection Move to a known skill, present
  another activity requiring less stress to perform
  etc.

28
De-escalation Techniques, continued

• Setting limits Remain calm and outline the
  expectation and clearly define the consequence of
  the behavior. If you strike at me I will have to
  leave the room. (withdrawal of attention)
• Withdrawal of attention Opposite of active
  listening. A very powerful technique especially
  when paired with active listening for
  reinforcement. This helps define the relationship
  between attention and calm interactive behavior.
• Contracting Clearly defines the parameters of
  expectation/not for avoidance of the task.

29
Crisis

• Physical aggression, i.e. property damage or
  aggression toward another
• Some include verbal aggression.

30
Recovery

• Level of activity is decreasing.
• Typically even the most aggressive individual
  cant keep up the energy level for a prolonged
  crisis period.
• The recovery side of the curve tends to be fairly
  steep.

31
Post Crisis Depression

• Characterized by behavior that falls below base
  line.
• The client may require a short rest period or a
  less active task until back at base line levels.

32
Successful Community Re-Settlement

• True community resettlement requires
  concentrated, well-planned efforts. It requires
  family and professionals, planning, clinical
  excellence, proactive treatment, creativity and
  resourcefulness.

33
Legal Model

• Legal categories of assaultive behavior
• Simple assault Threatening gestures or speech
• Assault and battery Physical force and threats
• Aggravated assault Attempt to cause serious
  bodily harm
• Professional Assault Response Training
  manual

34
Reasonable Response

• Therapists can legally protect themselves against
  varying degrees of assault and are bound by
  reasonable response
• Simple assault communication
• Assault and battery evasive self defense
• Aggravated assault physical intervention may be
  called for but only from specifically trained
  individuals. ( PART, CPI, Law enforcement)

35
Medication

• Antianxiety, Antidepressant, Stimulants,
  Antipsychotic, Atypical Use.
• Whatever the Pharma intervention it must be
  closely managed Neuropsychiatry is a must and
  monitor for impact.

36
Conclusion

• The place where you stop when you are tired of
  thinking. Arthur Block