- SELF STUDY MODULES
- 1. Intro to TBI
- 2. Communication
- 3. Skills for independence
- 4. Cognitive changes
- 5. Behaviour changes
- 6. Sexuality
- 7. Case management
- 8. Supervising staff
- 9. Mobility & motor control
- 10. Mental health & TBI:
- 11. Mental health problems
and TBI: diagnosis
- 12. Working with Families
after Traumatic Injury:
5.4 Behaviour management
i) Behaviour management
There are behaviour management techniques and concepts that can be useful in managing behaviour changes following a TBI
Read through the following list of techniques and then work on:
- Case Study A : Jack
- Case Study B : Tim
Common behaviour management techniques
This serves to maintain or increase behaviour, as a result of the individual seeing the consequence of the behaviour as something positive. Positive reinforcement can be tangible (If I work hard, I will get a raise) or social (praise or smile).
This also serves to maintain or increase behaviour. In this case we do something to prevent a negative outcome. Negative reinforcement can be tangible (If I stick to the speed limit, I will avoid a fine and I will keep my licence) or social (being ignored).
Punishment is when something unpleasant follows a behaviour, which results in a reduction of the behaviour. For example, ‘The last time I punched someone, I ended up in jail – This time I will not use violence, I will walk away’.
This occurs when you withhold reinforcement for a specific behaviour. It is common when using extinction to see an initial increase in the behaviour. For example, making a commitment to totally ignore inappropriate comments made by a person with TBI will initially result in the person becoming more vocal and explicit. Continue to ignore inappropriate comments and they should decrease/cease over time.
Differential reinforcement of other behaviour (DRO)
DRO involves reinforcing someone for not engaging in a particular behaviour. There are many different types of DRO, such as differential reinforcement of alternative responses or differential reinforcement of incompatible responses. With DRO any response, whether it is desirable or not, is reinforced so long as it is not the response to be eliminated. For example, if your goal is to encourage an individual to socialise with others, they would be rewarded for just coming out of their room, whether they participated in the program/ talked with others or not.
Timeout is when a person is removed from the source of reinforcement for a specific period of time. Timeout may refer to isolation, as in a timeout room, or contingent observation, such as being able to watch activities but not participate in them. Timeout should be no longer than five minutes.
Time out on the spot (known as TOOTS) simply involves walking away from the person without saying anything to give them time to calm down. Return a few minutes later and continue your interaction with them.
A response cost is the ‘price paid’ when an individual exhibits an undesirable response, which results in a loss of privileges or other reinforcement. For example, if you use a point/token system, you start with a set number of points/tokens and the person is 'charged' a predefined number of points/tokens for a particular undesirable behaviour. At the end of the week/time period, the points would earn them a reward. For example, ‘If you have over 80 points left you can buy the motor bike magazine you want’.
There are two types of overcorrection procedures that you may be familiar with. During restitutional training, a person is required to make restitution by returning the environment to a better condition than its original state. For example, if you throw some rubbish out in the driveway – then you have to pick up all the rubbish in the driveway. The other type, positive practice, involves the person practicing the correct response repeatedly. For example – if someone does something in a sloppy fashion, then they not only do that task over again but must also perform another task neatly.
Case study A: Jack
Jack is 44 years old. He lives at Hoxton Park with his wife, who works full time. They have two children aged 15 years and 6 years. Pre-injury hobbies include model shipbuilding and gardening (his wife has reported that he takes great pride in his garden).
Details of injury
Jack was working as an electrician and fell off a roof. He sustained a frontal brain injurys and has residual weakness in his left arm. Neuropsychological assessment indicated that he is concrete and rigid in thought. At times he can also be inflexible and mildly impulsive. His memory/learning ability remain fairly intact.
Goals within TLU
Jack spent some time in the acute rehabilitation ward in hospital before transferring to a share house in the community (a Transitional Living Unit or TLU) to continue rehabilitation. The primary goal within the TLU is to assess his independence and increase the functionality of his left arm
The TLU is currently full of young males, with whom Jack has nothing in common. Staff find that he constantly gravitates toward them and that he is always hovering around the office doorway. When he speaks with staff, it is mostly to complain about the other residents (complaints range from ‘dobbing on them’ about tasks not completed to criticisms of their character and the ‘youth of today’). On the odd time, staff have witnessed low level frustration toward the other residents, with the occasional verbal outburst. No real aggression has been noted.
Answer the following questions
b) What do you want the outcome to be?
c) Is there anything currently reinforcing this behaviour (Are staff making this worse?)
d) What potential reinforcers are available to you?
e) Devise a way to use this reinforcer to manage this behaviour.
f) Are there other issues you need to consider?
Main Problem : Boredom
Outcomes: Reduce dependence/interaction
on/with staff, reduce time spent hovering
around the office door, reduce complaining behaviour, encourage independent
reinforcing his behaviour: Social interaction/conversation
staff providing an empathic ear.
Potential reinforcers: Gardening, ship building, children/home visits
A. Provide positive or differential reinforcement for
participating in any other
activity other than complaining to staff and office door hovering.
B. Schedule/assist him to plan and carry out other
building/gardening) and provide verbal/social reinforcement when he is
carrying these activities out.
C. Extend Home visits to long weekends to increase time with family.
issues: Monitor anger management/frustration
intolerance and consider referral
for anger management. Consider relevance of TLU program and address issues via
community program if more beneficial to client.
Case study B: Tim
Tim is a 21-year-old carpenter. He lives alone in a house at Bankstown with his German Shepherd dog, which he adores (his sister lives 15 minutes away and will only mind the dog until he is discharged). Tim denies having any hobbies, but reported that he used to play indoor cricket on a regular basis. His other interests included rally cars and ‘clubbing’ with his mates.
Details of injury
Tim was a passenger in a motor vehicle accident. The driver died. Neuropsychological assessment indicated an overall lowering of functioning. He had mild learning/memory problems, poor planning and poor problem solving skills, and his attention and concentration were below average.
Goals within TLU
Tim spent some time in the acute rehabilitation ward in hospital before transferring to a share house in the community (a Transitional Living Unit or TLU) to continue rehabilitation. The primary goal within the TLU is to assess his independence, improve his fitness levels and returning him to independent living.
Staff find it hard to motivate Tim to participate in the program. He frequently sits alone and appears lethargic. He occasionally becomes argumentative when prompted by staff to attend appointments and groups – and retreats to his room if allowed. He does not understand why he needs to be at the TLU and would prefer to lie in bed all day.
Answer the following questions
b) Is there anything currently reinforcing this behaviour (Are staff making this worse?)
c) What potential reinforcers are available to you?
d) Devise a way to use this reinforcer to manage this behaviour.
e) Are there other issues you need to consider?
Main Problem: Depression/grief
Outcomes: Increase activity /participation in program, decrease
time spent thinking
reinforcing his behaviour: Avoids participating and gets
to spend time
Potential reinforcers: Dog, rally cars (could include races, magazines, TV coverage)
A. Reinforce all time spent out of his room.
B. Ask sister for access to the dog, encourage outdoor activity/interaction
the dog (walking it, taking it to the park, bathing it, brushing it etc).
C. Encourage participation in program with a reward for predetermined
amount of participation (e.g.: attend 3 groups and we will then take your dog
to the park to play for 1 hour, or your mates will take you to the rally car event
issues: May need counselling for depression/grief, and/or
Case study C: Andrew
Andrew is a 35 year old man who lives with his wife and three young children., 8, 5 and 3 years old. He has been discharged from the rehabilitation unit and is now at home and attending a ‘return to work’ programme 3 days a week. His hobbies are playing computer games and watching rugby league games on T.V.
Details of injury:
He had a severe brain injury resulting from a fall of 3 metres at work; he works as an electrician. He has recovered well physically but has a low frustration tolerance and some difficulties with planning and organisation.
His wife reports that he shouts and swears at his young children quite frequently and his children are becoming reluctant to spend any time with him. She then becomes upset with him as she thinks his expectations of how the children should behave are unrealistic for their ages. He believes that she is too soft on the children and doesn’t discipline them enough. This conflict at home is affecting his ability to participate effectively in his ‘return to work’ programme.
This case requires outside intervention.. Andrew and his wife should be referred to a psychologist or family therapist to discuss the problem .
- The therapist will ask whether there are particular times at which this behaviour occurs eg during busy periods at home such as when the children first arrive home from school.
- They would suggest that at these times Andrew should withdraw to another room if he felt he was becoming irritated with the children.
- They would also ask Andrew whether he would agree to participate in an anger management programme
- The family therapist would talk with Andrew and his wife to address their different parenting styles