Applied Behavior Analysis and the Way We Respond in Cases of Traumatic Brain Injury

Applied Behavior Analysis and the Way We Respond in Cases of Traumatic Brain Injury

Vanessa Bracero, MS, BCBA

The majority of inappropriate behaviors in individuals with Traumatic Brain Injury (TBI) are related to the injury and each individual’s current level of function. The behaviors are not just because the individual wants to be difficult. This shift in mind-set may make the world of difference on how a supportive family member or caregiver handles certain behaviors and situations. It could be a positive and effective interaction or it could be a detrimental one depending on the family member’s understanding and education regarding behavioral issues. It is not uncommon for family members to feel their loved one is “lazy” or “hard headed” (common references to these behaviors) when they come home from the hospital or rehabilitation facility.

We expect behaviors to be socially appropriate and this is no different for individuals with traumatic brain injury. Pro-active measures are appropriately assessing and developing interventions and interactions that are effective and lead to successful outcomes.  Below is a list taken from basic behavior analysis principles. These methods are positive and productive interactions when working with someone with a traumatic brain injury:

1. Always, and when able, involve the person in decision making and include his or her preferences, wants and needs as much as possible in every aspect of his or her life.
2. When talking, speak slowly using a normal voice.  Use simple words and short sentences.  This will make a point and decrease frustration and confusion.
3. Keep interactions positive. Statements should be positive even during negative situations or interactions.  ie:  “That was difficult for you to do, Joe, but you walked away. That’s great!”
4. Present options and choices. i.e.,: “Would you like to do ____or do _____?” It is best to present situations to promote problem solving and empowerment. Show respect always.
5. Minimize interruptions, distractions and changes to schedules.
6. Remain calm and gently ask how you can be helpful if tone or voice becomes elevated or words are inappropriate or if behavior escalates to yelling or screaming. Ask for help if behavior escalates to physical aggression (hitting or throwing objects).
7. Be aware of basic needs such as hunger/mealtime, fatigue, too much stimulation, or orientation. By recognizing these needs, conversations will be more productive and constructive.
8. Deliver enthusiastic verbal praise whenever engaging in any appropriate behavior. Specifically staying on one topic at a time, completed tasks independently, remembering things accurately, when requesting help appropriately etc. Research suggests that reinforcement and concentrating on the positive may result in more positive behaviors in the future which promotes a better learning environment.
9. Provide one step directions until task completion or between several tasks. Watch for responses and determine if task should continue or if modifications are needed.
10. When providing information on a task to be performed, ask the individual to repeat back and then praise restatement or make clarifications as needed. Repeat this step as often as needed until learning occurs.
11. Ask if he or she would like you to model a task, if there may be something unfamiliar or unsafe in his or her opinion.  Once complete, observe the task being completed. If needed, work in steps until the task is accomplished. Trials may be needed until learning occurs.
12. Allow additional time to process information or to begin a task. Ask if clarification is needed or if additional time is needed.  Prompt to request additional time, such as: “May I have a few more minutes to think please?” or “May I see that again?”  Follow with praise and allow additional time, continued practice, repetition.
13. Ask if a visual aid would help so it can cue memory, locate his or her room, the dining area, look for his or her schedule, or help find areas/markers that will be visual aids to access home and community safely and effectively.
14. When transitions take place, provide a lead time of 5-10 minutes and state there is time to prepare, allow time to shift.
15. When it is time to transition or introduce a new activity or task, explain step by step, if necessary, using simple words as to what will occur (see above).
16. Do not argue. Arguments can lead to confrontation. Take a break from the conversation and revisit the topic later.
17. Confabulation is not uncommon in TBI.  This is where an individual appears to make up stories. It is actually the result of not being able to effectively communicate so the individual with TBI “fills in the blanks” to maintain any conversation.  Some stories and behaviors may have to be ignored with the topic redirected toward another appropriate topic. This redirection is best accomplished in a calm manner. A change in the location or environment is simultaneously effective as long as discussion is not threatening. A cognitive therapist is most helpful in this area.
18. Help organize. Allow choice and preferred tasks and establish a routine/schedule. Maintain this routine so he or she learns to expect what is routine or on his or her schedule each day. Maintain one subject at a time during conversations. Gently refer or redirect conversations until the conversation on that topic is completed. It is ok to say “Let’s go back to talking about ________and you can tell me about ________ as a way to return to the previous conversation.
19. New learning can best be achieved through the use of role playing. Put all situations into role plays and model and practice and praise, model and practice and praise … practice!
20. Promote learning at all times. Ask “What do you need in order to______?” “How can I help you with __________? Encourage, encourage!
21. Look for patterns between behaviors and environmental factors and work to rearrange the environment and minimize and prevent problem behavior, decrease aversive situations and develop a plan on future responses.

What we learn is how we are what helps change behaviors in others. We cannot change those behaviors. We change our interactions, pay closer attention, and realize how important our actions impact others around us.

Vanessa Bracero

Behavior Specialist Vanessa Bracero, Board Certified Behavior Analyst, obtained her master’s degree in Applied Behavior Analysis from The Florida Institute of Technology and has been in the behavior analysis field more than 16 years. View Bio