Applied Behavior Analysis: Concepts,
Principles and Methodology for the
Brain Injury Practitioner to address the
challenges of neurobehavioral issues in
post-acute rehabilitation.
Presenters:
Chris Schaub, MscEd, BCBA
Christina Peters, MscEd, BCBA, CBIS
Overview & Objectives
This half day workshop will provide:
1.
To provide an overview of behavior analytic philosophy, principles and
procedures toward developing effective interventions for specific target
behaviors.
2.
To present broad guidelines for developing and implementing
comprehensive, interdisciplinary treatment programs for individuals with
intensive neurobehavioral needs, including aggression, elopement,
resistance, dual diagnosis, etc...
3.
To share information that will help clinicians, staff, funders and
administrators within the field identify and prioritize treatment plan
elements that are essential to integrated, comprehensive neurobehavioral
rehabilitation.
Clients we serve…
• Are difficult to place following acute
rehabilitation
– Medical complexity results in and/or is complicated
by neurobehavioral instability
• Medication issues
• Sleep disturbances
• Vestibular Disorders
• Chronic Pain
• Unresolved issues with bowel and bladder function
• Unresolved eating and hydration issues
• Post-traumatic confusion
Clients we serve…
• Exhibit emergent, persistent or pre-existing
issues that prohibit progress (at any level)
– At risk behaviors and/or safety concerns secondary
to awareness deficits
• Refusal & Resistance
• Substance Abuse
• Aggression
• Threats & Violence
• Sexual disinhibition
• Pre-existing MH issues
Clients we serve…
• Have been discharged to the home
environment and are too challenging for the
family/caregiver
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Programming not available, limited and/or lacks integration
Behavioral stability is questionable
Change in behavioral patterns
Change in medical stability impacts mood, behavior,
cognition, etc…
– Acute/emergent destabilization
– Danger to community/family or self
Post-Acute Neurobehavioral
Rehabilitation at ReMed
Neurobehavioral Sequelae
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Medical complexity
PTA
Persistent cognitive impairment
Acute medical/behavioral
instability
Resistance/Refusal
Threats & Aggression
Wandering & Elopement
Substance abuse
Co-occurring issues
Interdisciplinary Team
• Physiatry, Neuropsychiatry,
Neurology & Consultants
• Nursing
• PT
• OT
• SLP
• Psychology & Neuropsychology
• D&A Counselor
• Behavior Analyst
• TR
Evolution of
Neurobehavioral Programming
• Admission & Stabilization
– Priority is typically medical and/or behavioral stability
– Frequently precedes comprehensive rehabilitation efforts
• Evaluation & Treatment
– Interdisciplinary team completes evaluations, identifies goal
areas and establishes treatment plan
– Integrated programming and rehabilitation supports stability
and progress in key areas
• Generalization & Maintenance
– Trials, education and training support efforts to expand
programming and maximize independence
– Consider transitions and/or discharge planning
Importance of Philosophy
• Guides interdisciplinary team in comprehensive
assessment and treatment efforts
• Provides clinical framework for prioritizing
issues
• Enables treatment programming to be highly
individualized
• Promotes integration at all levels and areas of
programming
Neurobehavioral Philosophy:
3 Keys to Stability & Success
Establish
Medical Stability
Promote
Behavior Stability
& Cognitive
Enhancement
Comprehensive
&
Integrated
Programming
Develop
Stable Activity Plan
Establish
Medical Stability
Promote
Behavior Stability
Develop
Stable Activity Plan
Sources of Medical Instability &
Interdisciplinary Involvement
Issue(s)
• Pain
• Vestibular
• Medication regiment and
compliance
• Poor Sleep
• Bowel/Bladder Incontinence
• Drug and Alcohol Use
• Acute, unresolved or
pre-existing medical
issues/conditions
Team Member(s)
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Physiatrist
Neuropsychiatrist
Neurologist
Consultants
Rehab Nursing
PT
D&A
BA
Establish
Medical Stability
Promote
Behavior Stability
Develop
Stable Activity Plan
Characteristics of Behavior Instability &
Interdisciplinary Involvement
Issue(s)
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Confusion/Disorientation
Poor/Limited Awareness
Refusal/Resistance
Mood Instability
Threatening/Demanding
Verbal &/or Physical
Aggression
• Property Destruction
• Elopement
• Substance Use
Team Member(s)
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Neuropsychiatrist
Neuropsychology
Psychology
BA
D&A
OT
PT
TR
Establish
Medical Stability
Promote
Behavior Stability
Develop
Stable Activity Plan
Features of an Unstable Activity Plan &
Interdisciplinary Involvement
Issue(s)
• Poor follow through &/or
initiation
• Limited choice
• Imbalance of reinforcement
availability/potency with
regard to preferred activities
• Inattention to risks
associated with competing
reinforcers or inaccessibility
of support
Team Member(s)
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TR
OT
PT
Psych
BA
Cog
D&A
The Analysis of Behavior:
Key Points
•Definition of behavior includes thinking, saying
and doing
•Behavior occurs, interacts with the environment
and produces consequences
•Darwinian-like model wherein behaviors are
selected by the environment
•The goal of behavior analysis is to enable
prediction and change of behavior
Two Types of Learning
Operant
Respondent
• Concerned with
environmental events
that precede target
responses.
• Concerned with
environmental events
that follow the responses
(its consequence)
•S
•R S
R
Operant Conditioning
• But as you probably already noticed, we do not simply
react to stimuli in the environment.
• Based on our history, we also act in ways that affect or
change the environment.
• Operant conditioning is a training or learning process
by which the consequence of a response affects the
likelihood that the individual will produce that
response again.
The Three and Four Term
Contingency
The familiar…. 3 Term
A→B→C
The more precise… 4 Term
_
D
+/
E.O. → S → R → S
The Four Term Contingency
Establishing Operation: Any change in the environment that alters the
effectiveness of some stimulus or event as a reinforcer.
Discriminative Stimulus: An event or stimulus that precedes a response and
sets the occasion for the behavior to occur.
Response/Behavior: "If a dead man can do it, it ain't behavior. And if a dead
man can't do it, then it is behavior"
Stimulus: Any event that changes the probability of a response when presented
after it: S+ refers to a stimulus that increases the probability of a behavior
occurring, and S_ refers to a stimulus that decreases the probability of a
behavior occurring…but more on that later.
Reinforcement
Reinforcement refers to any process that increases the
likelihood that a particular response will occur again
in the future.
Positive Reinforcement occurs when the arrival/delivery
of some stimulus following a response makes that
response more likely to occur in the future.
Negative Reinforcement occurs when the removal of a
stimulus following a response make that response
more likely to occur.
Punishment
Punishment refers to any process that decreases the
likelihood that a particular response will occur again
in the future.
Positive Punishment occurs when the arrival/delivery of
some stimulus decreases the likelihood that the response
will occur again.
Negative Punishment occurs when the removal of some
stimulus decreases the likelihood that the response will
occur again.
Positive
R
E
I
N
F
O
R
C
E
M
E
N
T
P
U
N
I
S
H
M
E
N
T
A stimulus is added such that the
likelihood of the behavior
increases.
A stimulus is added such that the
likelihood of the behavior
decreases.
Negative
A stimulus is removed such that
the likelihood of the behavior
increases.
A stimulus is removed such that
the likelihood of the behavior
decreases.
R
E
I
N
F
O
R
C
E
M
E
N
T
P
U
N
I
S
H
M
E
N
T
Positive
Negative
A day laborer is paid after 8 hours
of work, as a result they return the
next day.
After hitting the snooze button the
alarm goes off, as a result the
snooze button is used more in the
future.
A pink slip is issued to the late
employee, as a result the
employee begins to come to work
late less often.
A fine is issued to a driver for
speeding, as a result the driver
speeds less frequently.
Function
• Function is the behavior analytic term that refers to “why" an
individual exhibits a certain behavior; specifically, it refers to
those consequences that maintain the behavior.
• Often, an individual will display a number of behaviors that
may differ in topography but share a similar function; these are
referred to as Functional Classes of Behavior.
• All operant behavior occurs within some context, and
understanding this context is key to modifying any behavior.
Schedules of Reinforcement
• Extinction: A particular response never
produces a reinforcer.
• Continuous Reinforcement: A particular
response always produces a reinforcer (1:1).
• Intermittent Reinforcement: A particular
response sometimes produces a reinforcer.
Continuous Reinforcement
• Produces less variability
in topography of
behavior.
• Utilized to promote
acquisition of behavior
• Behavior is highly sensitive
to extinction
• Think piece work and
soda machines
Intermittent Reinforcement
• Produces greater
variability in topography
of behavior.
• Utilized to promote
generalization and
maintenance of behavior
• Behavior is highly
resistant to extinction
• Think hourly pay and
slot machines
Why Do We Need to Know About
Schedules of Reinforcement?
• In order to understand what is maintaining a
particular behavior we not only need to look at the
function of that behavior, but also the schedule on
which it is being reinforced or maintained.
• Behaviors within the same functional class can be
sensitive to concurrent schedules of reinforcement,
making analysis more critical.
• Attempting to intervene without this knowledge could
result in danger to client or others.
Establish
Medical Stability
Promote
Behavior Stability
Develop
Stable Activity Plan
Establish Medical Stability:
Principles and Programming To Be Considered
Principles
Programming
• Establishing operations
• Crisis Plan
• Antecedents
• Structured routine
• Acknowledge limited
• Data collection
efficacy of consequencebased programming
• Identify and define target
behaviors
• Establish criteria for
stability
• Prioritize behaviors and
expectations
Establish
Medical Stability
Promote
Behavior Stability
Develop
Stable Activity Plan
Promote Behavior Stability:
Principles and Programming To Be Considered
Principles
Programming
• Function
• Preference Assessment
• Reinforcement
• Functional Analysis
• Contingencies, Schedules &
Potency
• Specific procedures & tools;
• NCR, DR and EXT
• Extinction
• Shaping, chaining and fading
• Generalization
• Criteria Checklists & Phase Plans
• Maintenance
• Data-based decisions
Establish
Medical Stability
Promote
Behavior Stability
Develop
Stable Activity Plan
Develop Stable Activity Plan:
Principles and Programming To Be Considered
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Principles
Schedules of reinforcement
Potency of reinforcers
Differential reinforcement
Generalization
Maintenance
Premack Principle
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Programming
Pacing
Continue data-based
decision making
Refine and work towards
criteria for stability and
safety
Promote generalization and
maintenance of skills
Continuum-based
Neurobehavioral Programming
• Critical questions often are at the core of the
post-acute process
• Must consider and address challenging and
complex sequelae across treatment areas
• Must take into account funding and available
time and resources
• Need to answer questions in clear and accurate
manner
Building Towards Independence
• Identify component skills necessary
• Determine how best to promote acquisition
• Consider combinations of skills
• Generalization and maintenance
• Use multiple differential reinforcement
contingencies
Sample Data Collection
Tool #1
“Phase Plan”
Sample Data Collection
Tool #2
“Criteria Checklist”
Sample Data Collection
Tool #3
“Individualized Daily Schedule”
Promoting Movement Towards Less
Restrictive Setting
• Work begins at STIRS with the interdisciplinary team.
• Team supports client to participate in the plan to maximize
stability and independence
• Less restrictive placement options are explored and trialed,
which can include transitioning within ReMed’s
continuum or beyond
• The plan ultimately guides readiness-based decisions or
conclusions by providing objective behavior data
• The structure of the plan mitigates issues related to awareness
deficits in such a manner that they are not necessarily a
barrier to progress
Sample Data Collection
Tool #4
“MacroTracker”
Case Study #1
‘Sara’
“Sara”
Psycho-Social Profile
• 29 years post injury, injured at 15 years old.
• History of admissions and discharges to/from various inpatient facilities
secondary to behavioral dyscontrol.
• Use of ‘medication interventions’ and inpatient admissions to stabilize
aggressive behaviors.
• Risperidone introduced with significant negative side effects.
• Admitting from home where care giving responsibilities were shared between
family, friends and one hired caregiver secondary to burnout.
• Family states that they are prepared to take her back home following
admission but only if things are different.
“Sara”
Clinical Profile
– Aggression (hitting & kicking
caregivers and family
– Threatening
– Sexually Inappropriate
Behavior
– Mood instability
– Impulsivity
– Residual Cognitive
Impairment
– Poor Self Awareness
– Bowel and Bladder
Incontinence
– Confusion/Disorientation
– Resistance/Refusal of
Medications
– Non-reality based statements
accompanied with
emotionality.
– Falls Risk
– Sedation secondary to
medication; decreased
mobility, poor posture,
drooling, reduced swallow
response.
“Sara”
Referral Questions & Client Goals
• Referral Questions
– Why haven’t other attempts to stabilize and return to home worked?
– Can Generalization and Maintenance be achieved? If so, how?
– Can there be a protocol be for managing future episodes of destabilization so that last resort interventions can be avoided?
• Client Goals
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Return home
Be more independent
Access the community more often
Relationship
Case Study #2
‘Melissa’
“Melissa”
Psycho-Social Profile
• 10 years post injury
• History of treatment non-compliance, psychiatric admissions, several arrests
for possession
• Multiple admissions previously to residential and outpatient brain injury
programs
• Admitting from apartment situation; currently exhibiting issues with relapse,
mood instability, refusal/resistance to treatment; high risk behavior
• Accessing community but no work/volunteer situation, not attending
fellowship/AA, limited social network and/or leisure options
• Family not prepared to have them live at home under any circumstances
“Melissa”
Clinical Profile
– Executive dysfunction
• Impulsivity
• Impaired judgment and problem solving
• Poor frustration tolerance
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Poor awareness
Mood instability (lability, history of depression)
History of Substance Abuse
Verbal & Physical Aggression, Property Destruction
Sexually Inappropriate/At-Risk Behavior
Elopement Risk
SIB (cutting, burning)
“Melissa”
Referral Questions & Client Goals
• Referral Questions/Objectives
– Are you willing/able to provide treatment ?
– Promote and establish safety
– Encourage treatment participation
– Optimize independence
• Melissa’s Goals
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Live independently
Work competitively
Drive
Relationship