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
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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
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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
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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
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Examples of Cognitive and
Behavioral Changes After ABI / TBI
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Orientation
Alertness
Focusing Attention
Speed of Processing
Remembering New Info
Remembering Past Info
Perception of
Environment
• Expressive language
• Receptive language
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Fatigue
Executive Skills
Reasoning
Sequencing
Multi-tasking
Behavioral Control
(start, stop, & resisting
impulse)
• Emotional Control
(inappropriate or intensity
change)
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What is Functional Analysis?
Assessment process for gathering
information to inform treatment
 Interview
 Direct observation over time
 Systematic manipulations
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Functional Analysis
ABC Model
“A”
Antecedents
“B”
Behavior
“C”
Consequences
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ABC Model: “B” Behavior
“B”
Behavior
Describe the behavior
What does it look like?
Frequency
Duration
Intensity
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ABC Model: “A” Behavior
“A”
Antecedent
B
•What factors preceded the behavior?
•People
•Places
•Objects
•Time of day
•Activities occurring
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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.
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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?
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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
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Examining Consequences
Why it occurs?
• REINFORCERS
• PUNISHERS
– Anything given or
– Anything given or
taken away that
taken away that
increases
decreases likelihood of
likelihood a
a behavior occurring
behavior will occur
again.
again
– Person specific
– Person specific
– Situation specific
– Situation specific
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Functional Analysis
ABC Model Summary
“A”
Antecedents
For example:
•People (+ or –)
•Places
•Things
•Events
•Time of Day
“B”
Behavior
Describe:
•Looks like
•Frequency
•Duration
•Intensity
“C”
Consequences
All things occurring
as a result of “B”
•What happened
•Reaction from others
•Get something
•Avoid something
•Other changes
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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
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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)
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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.
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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.
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Team Considerations
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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
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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)
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Family Considerations
• Educate
– Family conferences
– Regular meetings
• Embarassment factor
• ID and intervene with ineffective coping
strategies
• Explain importance of consistency
• Generalizability Issues
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Functional Analysis
CASES
“A”
Antecedents
For example:
•People (+ or –)
•Places
•Things
•Events
•Time of Day
“B”
Behavior
Describe:
•Looks like
•Frequency
•Duration
•Intensity
“C”
Consequences
All things occurring
as a result of “B”
•What happened
•Reaction from others
•Get something
•Avoid something
•Other changes
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Staff Considerations to Maximize
Appropriate Responding and Participation
Functional Analysis
ABC Model Summary
“A”
Antecedents
For example:
•People (+ or –)
•Places
•Things
•Events
•Time of Day
“B”
Behavior
Describe:
•Looks like
•Frequency
•Duration
•Intensity
“C”
Consequences
All things occurring
as a result of “B”
•What happened
•Reaction from others
•Get something
•Avoid something
•Other changes
Case 1: Background:
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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.
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ABC Model: “B” Behavior
“B”
Behavior
Describe the behavior
What does it look like?
Frequency
Duration
Intensity
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ABC Model: “B” Behavior
“A”
Antecedent
B
•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.
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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.
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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
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another discussion).
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).
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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.).
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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.
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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.
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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
• 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
• 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
• 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).