APPLICATIONS OF ABA IN PEDIATRIC MEDICAL REHABILITATION SETTINGS. Gregory Young, Ph.D., LABA, BCBA

Transcription

1 APPLICATIONS OF ABA IN PEDIATRIC MEDICAL REHABILITATION SETTINGS Gregory Young, Ph.D., LABA, BCBA

2 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Increasing population: Improved prenatal medicine more medically complex children are born Better neonatal and pediatric care individuals are living longer In many ways this is a new population

3 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Who are these children? Children with Cancer/Tumor Pre or post transplant/organ failure Genetic/Chromosomal abnormalities Acquired or traumatic brain injuries Encephalitis Strokes Motor Vehicle Accident

4 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Who are these children? Children with Movement disorder (paralysis/palsy, MS, spasticity) Respiratory issues (tracheostomy, BiPAP/CPAP, or Ventilator support) Feeding/GI issues Sickle Cell Cystic Fibrosis (CF) Diabetes Intractable seizures Chronic Pain Multi-system medical anomalies

5 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS What is your experience with this population?

6 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Who are these children? Children that require ongoing medical care, often from multiple medical specialties Frequent hospitalizations Complicated medical regimens and medication schedules

7 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS There is no biological vacuum Many children have a number of physiological anomalies in addition to cognitive impairments

8 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS These children are exposed to numerous hospitalizations and endure many painful and invasive medical procedures from birth. Mechanical restraints (i.e., welcome sleeves) and chemical restraints (i.e., sedatives and anesthesia) are used frequently.

9 CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Medical trauma Over generalized physiological arousal (classical conditioning) Systematic and accidental reinforcement of aggressive and disruptive behaviors (operant conditioning)

10 MEDICAL REHABILITATION SETTINGS Franciscan Children s: Medical Rehabilitation Kennedy Krieger Institute: Pediatric Rehabilitation Unit

11 MEDICAL REHABILITATION SETTINGS Franciscan Children s: Medical Rehabilitation 42 beds across two medical units The largest dedicated pediatric rehabilitation center in New England Service children as young as a couple months into early adulthood Length of stay varies from 1 to 2 weeks up to 5 to 6 years

12 PSYCHOLOGY S ROLE Neuropsychological Testing (snap shot assessment) Neurological Monitoring (progress monitoring) Adjustment to medical condition/hospital stay Coping with loss and end of life planning Discharge preparation

13 PSYCHOLOGY S ROLE Preparation for medical procedures Reducing problem behaviors Medical refusal Removal of medical equipment Self-stimulatory behaviors related to medical equipment Reducing impulsive behaviors Increasing motivation and compliance with therapies Monitoring behavioral problems Evaluating preferences and responses to stimuli Writing behavior plans Teaching independence of medical care Assisting in an individual s relearning of activities of daily living Parent and staff training

14 CASE STUDY 1: TOM 6 year old male Has lived on the rehab unit for 5 years Was born with lung disease and heart failure Needs a heart and lung transplant Was not expected to survive past 1 year

15 CASE STUDY 1: TOM Requires 24 hour ventilator support Improving medical stability Non-ambulating Non-verbal (signs more & all done and will point to the TV) Significant cognitive impairment

16 CASE STUDY 1: TOM Consult concern: Destroys trach and pulls trach off (self-decannulation) Risk: could cause death

17 CASE STUDY 1: TOM

18 CASE STUDY 1: TOM Step 1 Collect data

19 100 Percent of Behavioral Data Collected by Nurses A: Standard Written Instruction B: Computerized Prompts A B Average Per Phase % Collected Averag e Per Phase /25/2016 8/25/2016 9/25/ /25/ /25/ /25/2016 1/25/2017 2/25/2017 Date

20 100 Percent of Behavioral Data Collected by Nurses A: Standard Written Instruction B: Computerized Prompts A B Average Per Phase % Collected Averag e Per Phase /25/2016 8/25/2016 9/25/ /25/ /25/ /25/2016 1/25/2017 2/25/2017 Date

21 100 Percent of Behavioral Data Collected by Nurses A: Standard Written Instruction B: Computerized Prompts A B Average Per Phase % Collected Averag e Per Phase /25/2016 8/25/2016 9/25/ /25/ /25/ /25/2016 1/25/2017 2/25/2017 Date

22 100 Percent of Behavioral Data Collected by Nurses A: Standard Written Instruction B: Computerized Prompts A B % Collected Averag e Per Phase /25/2016 8/25/2016 9/25/ /25/ /25/ /25/2016 1/25/2017 2/25/2017 Date

23 CASE STUDY 1: TOM Step 2 Determine function Access to attention Access to water Self-stimulatory Step 3 Evaluate Interventions Reduce attention (low treatment adherence ineffective) Reinforce safe behavior (low treatment adherence ineffective) Aversive flavor (increased behavior) Sensory Extinction Abolishing operations

24 Daily Frequency of New Trachs Required 2.5 Baseline Noncontingent Access to 10ml Honey Thickened Water (Fixed Interval 1 Hour) Increased to 25ml 2 Occurrences Per Day Daily 0.5 Average Per Phase 0 12/15/ /17/ /19/ /21/ /23/ /25/ /27/ /29/ /31/2016 1/2/2017 1/4/2017 1/6/2017 1/8/2017 1/10/2017 1/12/2017 1/14/2017 1/16/2017 1/18/2017 1/20/2017 1/22/2017 1/24/2017 1/26/2017 1/28/2017 1/30/2017 2/1/2017 2/3/2017 2/5/2017 2/7/2017 2/9/2017 2/11/2017 2/13/2017 2/15/2017 2/17/2017 2/19/2017 2/21/2017 2/23/2017 2/25/2017 2/27/2017 3/1/2017 3/3/2017 3/5/2017 Date

25 2.5 Daily Frequency of New Trachs Required Baseline Deflated Cuff Noncontingent Access to 10ml Honey Thickened Water (Fixed Interval 1 Hour) Increased to 25ml 2 Occurrences Per Day Daily 0.5 Average Per Phase 0 12/15/2 12/17/2 12/19/2 12/21/2 12/23/2 12/25/2 12/27/2 12/29/2 12/31/2 1/2/2017 1/4/2017 1/6/2017 1/8/2017 1/10/2017 1/12/2017 1/14/2017 1/16/2017 1/18/2017 1/20/2017 1/22/2017 1/24/2017 1/26/2017 1/28/2017 1/30/2017 2/1/2017 2/3/2017 2/5/2017 2/7/2017 2/9/2017 2/11/2017 2/13/2017 2/15/2017 2/17/2017 2/19/2017 2/21/2017 2/23/2017 2/25/2017 2/27/2017 3/1/2017 3/3/2017 3/5/2017 Date

26 2.5 Daily Frequency of New Trachs Required Baseline Deflated Cuff Noncontingent Access to 10ml Honey Thickened Water (Fixed Interval 1 Hour) Increased to 25ml 2 Occurrences Per Day Daily 0.5 Average Per Phase 0 12/15/2 12/17/2 12/19/2 12/21/2 12/23/2 12/25/2 12/27/2 12/29/2 12/31/2 1/2/2017 1/4/2017 1/6/2017 1/8/2017 1/10/2017 1/12/2017 1/14/2017 1/16/2017 1/18/2017 1/20/2017 1/22/2017 1/24/2017 1/26/2017 1/28/2017 1/30/2017 2/1/2017 2/3/2017 2/5/2017 2/7/2017 2/9/2017 2/11/2017 2/13/2017 2/15/2017 2/17/2017 2/19/2017 2/21/2017 2/23/2017 2/25/2017 2/27/2017 3/1/2017 3/3/2017 3/5/2017 Date

27 2.5 Daily Frequency of New Trachs Required Baseline Deflated Cuff Noncontingent Access to 10ml Honey Thickened Water (Fixed Interval 1 Hour) Increased to 25ml 2 Occurrences Per Day Daily 0.5 Average Per Phase 0 12/15/ 12/17/ 12/19/ 12/21/ 12/23/ 12/25/ 12/27/ 12/29/ 12/31/ 1/2/2017 1/4/2017 1/6/2017 1/8/2017 1/10/2 1/12/2 1/14/2 1/16/2 1/18/2 1/20/2 1/22/2 1/24/2 1/26/2 1/28/2 1/30/2 2/1/2017 2/3/2017 2/5/2017 2/7/2017 2/9/2017 2/11/2 2/13/2 2/15/2 2/17/2 2/19/2 2/21/2 2/23/2 2/25/2 2/27/2 3/1/2017 3/3/2017 3/5/2017 Date

28 CASE STUDY 2: MAX 5 year old male Rare genetic deletion resulting in extremely low tone. Severe obstructive sleep apnea (OSA) and recurrent aspiration pneumonia (9 hospitalization in the past year) Diagnosed with autism - Highly verbal and impulsive

29 CASE STUDY 2: MAX Reason for admission: CPAP desensitization CPAP is an effective treatment in 86% of children with OSA Poor compliance and adherence occurred in 92% of the cases with poor outcomes (Marcus, Davidson-Ward, Mallory, 1995) Strategies based on the principles of Applied Behavior Analysis have been shown to be the most effective intervention (Koontz, Slifer, Cataldo, Marcus, 2003)

30 CASE STUDY 2: MAX Treatment package components: Positive & Negative Reinforcement Graduated Exposure Response Prevention (Escape Extinction) Distraction Counter Conditioning Stimulus Fading Demand Fading (Thinning the schedule of reinforcement) Systematic Generalization

31 CASE STUDY 2: MAX

32 CASE STUDY 2: MAX Step 1: Conduct sleep assessment Improve sleep hygiene Decrease sleep onset latency Decrease nighttime awakening Step 2: Baseline tolerance of mask Trial one: 3 seconds on hand Trial two and three: refusal to allow the mask to touch him

33 CASE STUDY 2: MAX Step 3: Gain basic compliance (High P) Establish SR + contingency (pretending to be racecars and running laps around play room) Step 4: High P (compliance task) Low P (mask on hand for 1 second) sequence with SR + (more running)

34 CASE STUDY 2: MAX Step 5: Demand fading (increase duration of mask on hand) Step 6: Move mask: hand forearm elbow shoulder ear cheek nose/face Step 7: Increase duration to 30 second

35 CASE STUDY 2: MAX Step 8: Stimulus fading (adding each component of the CPAP) Step 9: Shift away from running and generalize to bed Step 10: Use overnight, FC for breaks, escape extinction

36 CASE STUDY 2: MAX Notes: I ran miles Caregivers needed support during first extinction Consultation with medical (Pulmonary) team is essential Do not fade air pressure levels Do not connect the mask to the machine without the machine on Do not put a mask on a sleeping child By day 7 he was requesting the mask so that he could earn things Within a 15 day admission 3 years of battling was over

37 CASE STUDY 3: BEN 18 year old male with (at baseline): Cerebral Palsy (CP) Intellectual impairment Hearing Impairment Non-verbal (understood sign and could make some switch based choice) Non-ambulating

38 CASE STUDY 3: BEN Ben experienced severe Baclofen withdrawal following a Baclofen pump replacement. Resulting in frequent dystonic episode (dystonic storming): spasticity, muscle contraction, sweeting, elevated heart rate Not associated with a change in consciousness Very painful

39 CASE STUDY 3: BEN Goals of consult: Low responsiveness preference assessment Data collection

40 3 Preference Assessment Responses Number of Trials 2 1 Positive Neutral Negative 0 Arm Wrestling Water on Face Vanilla (Smell) Hand in Water Football Movie "Up" Massage Bubble Party In the USA Talking Stimuli

41 CASE STUDY 3: BEN Identified stimuli Arm Wrestling Water on Face Vanilla (Smell) Hand in Water Ben s day was imbedded with NCR using these stimuli Additionally these stimuli were evaluated as environmental strategies to decrease the length of dystonic episodes. ¾ of observed trials, there was a correlation between the use of these strategies and the end of the episode

42 CASE STUDY 3: BEN Data collection Very difficult to judge effect of treatment Variable rates of the behavior Emotionally distressing to watch the behavior 90 min episode and 60 min episode both feel equally as miserable Agitation: Any combination of two of the following: heart rate above 130, grinding teeth, one of his legs being elevated by his own effort, negative or distressed vocalizations or moaning, significant contractions of arms, significant shaking of body, and/or sweeting. Momentary time sample once per hour

43 Baseline Agitation Dantrolene Rampt to 100mg Dantrolene 50mg No Dantrolene Risperdal.5mg Risperdal 1.0mg Ratio of Intervals with Agitation by Number of Intervals Collected Date

44 CASE STUDY 4: JEN 12 year old girl Admission due to a sudden stroke while walking down the stairs at home Previous healthy high achieving child Home schooled by mom Current presentation: Non-verbal, non-ambulating, responsive to environmental stimuli, and seemed to have good receptive language

45 CASE STUDY 4: JEN Reason for consult: Motivation during therapies. Therapy was hard and painful and she would refuse to comply to demands. Conducted intake with mom Identified horses as her highest preferred topic Observed several therapy sessions Hypothesized escape was the functions Created a horse based token system with brakes from therapy as the backup reinforcer

46 CASE STUDY 4: JEN Conducted a co-treat with PT While in the stander, the patient was asked to make specific motor movement Patient complied and earned her first token Patient wanted to continue to look at the rest of the horse pictures but was prompted back to her work and the pictures were removed Patient became upset and started to cry Mom got upset and asked me to leave

47 CASE STUDY 4: JEN This case represents the greatest clinical mistake I have ever made (that I know about). What did I do wrong? I did not develop a strong enough relationship with the mother or patient I did not consider the emotionality of this case I was too rigid I did not consider/trust the mother s role as her teacher

48 CONCLUSION Research in adult psychotherapy has shown that the strength of the therapeutic relationship is the greatest predictor of positive outcomes Better predictor than therapeutic modality What matters in life is forming meaningful relationships What matters in our work is forming meaningful relationships

49 QUESTIONS