Behavior Management. David Krych, MS-CCC-SLP ReMed Recovery Care Centers

Transcription

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 n=722 patients mean 4 years p.i. 42% Depression Draper et al, 2007 n=53 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= % id d 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, % 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 isn t 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. 1. Coup Contra-coup = Diffuse Axonal Injury 2. Involvement of Frontal Lobes in TBI is well documented: Levin, H 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 1. Increased rest time - monitor and reduce as fatigue lessens. 2. Keep the environment simple and predictable: Beware over stimulation. 3. Keep instructions simple: Try not to over verbalize. 4. 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

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25 Trigger Stimulus or event that exceeds the client s 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 can t 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 1. Simple assault : Threatening gestures or speech 2. Assault and battery : Physical force and threats 3. 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 1. Simple assault: communication 2. Assault and battery: evasive self defense 3. 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