Behavior Management in Residential Brain Injury Settings

Judith Falconer, Ph.D.

WHO IS THE BRAIN INJURED INDIVIDUAL?

Until the injury, the person was like you and me. He/she probably worked or went to school, contributed to society, loved and was loved, had fears and worries, experienced pain and joy. We frequently fail to understand that until the injury, the person was a fully functioning member of a family, work group, and society. Until we understand the person behind the brain that was injured, we can do little to restore that person to a more functional life. We must delve beyond the current behavior and discover hidden strengths and weaknesses, pride and sorrow, accomplishments and failures.

WHAT CONTRIBUTES TO BEHAVIOR PROBLEMS FOLLOWING BRAIN INJURY?

1. Pre-injury variables:

• Age
• Intellectual skills (communication skills, learning style, etc.)
• Personality traits (dependency, assertiveness, motivation, etc.)
• Health
• Social support
• Education/work patterns

2. Acute medical treatment variables:

• Severity and length of coma
• Nature of injury (diffuse plus localized effects)
• Other medical complications (orthopedic, respiratory, etc.)
• Medical environment
• Family involvement

3. Post acute treatment variables

• Time since injury
• Physical recovery
• Treatment environments (physical & psychological)
• Nature and involvement of family
• Financial status
• Motivation for recovery

4. Additional critical variables

• Staff burnout level
• Family burnout level
• Availability of treatment options
• Availability and implementation of behavior management strategies
• Availability of cognitive retraining strategies

WHAT IS BEHAVIOR MANAGEMENT?

1. A way to analyze behavior and modify maladaptive behavior

2. A frame of mind which assumes that all behavior is learned and that all behavior is maintained through reinforcement

OBJECTIONS TO BEHAVIOR MANAGEMENT:

• Dehumanizing
• Too time consuming
• Too complex
• Not necessary
• Only a gimmick
• Fear of being disliked by client/family/other staff

HOW TO DO BEHAVIOR MANAGEMENT: THE NUTS AND BOLTS

1. Be patient. Change will occur very slowly.
2. Be consistent
3. Expect the unexpected
4. Don't overstimulate
5. Treat adults as adults
6. Remember, rehabilitation is a learning process
7. Reinforce appropriate behavior
8. Ignore inappropriate behavior unless it is dangerous to the brain injured individual or others
9. YOU ARE THE MOST POTENT REINFORCER AVAILABLE TO THE INDIVIDUAL.

BEHAVIOR MANAGEMENT PROCEDURES:

1. ANALYZE TOTAL BEHAVIOR PATTERN --- Determine which behaviors:

1. occur with excess frequency, intensity, or duration
2. fail to occur with sufficient frequency, adequate intensity, or appropriate form
3. the individual can do particularly well
4. the individual did particularly well in the past

2. SPECIFY PROBLEM BEHAVIORS & SITUATIONS

1. when/where they occur
2. frequency of occurrence
3. length of occurrence
4. intensity
5. individuals present during occurrence
6. what precedes them
7. consequences
8. what has already been tried

3. SPECIFY CURRENT/POTENTIAL REWARDS/PUNISHMENTS

1. Material Time Out
2. Activity Restraints
3. Social Withdrawal of social contact
4. Token Loss of privileges or reinforcers
5. Covert

4. ESTABLISH BEHAVIORAL GOALS

1. Select specific behaviors to be increased, decreased and/or added
2. Do not leave behavior void
3. Do not attempt to change multiple behaviors simultaneously

5. SELECT APPROPRIATE INTERVENTIONS

1. Utilize client's strengths
2. Minimize effects of client's deficits
3. Decide to change:

1. Environment
2. Other people
3. Client

4. Establish realistic time frames
5. Be realistic about expectations of:

1. Self
2. Client
3. Other people
4. Environment

6. IMPLEMENT BEHAVIOR PROGRAM

1. Inform/train everyone involved
2. Give program a chance to work before giving up or changing it
3. Expect client to test your determination to succeed
4. Be consistent
5. Be patient

7. MONITOR PROGRESS

1. Keep detailed records
2. Be consistent
3. Involve client in monitoring
4. Fade reinforcers gradually
5. No holidays allowed

8. MAINTAIN NEW BEHAVIOR PATTERN

1. Prayer may be appropriate
2. Recycle if necessary

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