A common misunderstanding of Applied Behaviour Analysis (ABA) is that we only work with Autism – It is so much more than that! It is the application of behaviour principles to a much wider range of population, conditions and situations!
Brain injury has been referenced in many behaviour analytic literature over the years. Of the interventions discussed in the brain injury literature, positive reinforcement, modifying antecedents (adding visual cues, modifying schedules and self-management) were classified as well-established and effective for acquiring skills and adaptive behaviour. In addition to self-management and antecedent control, extinction and differential reinforcement is well-established for reducing challenging behaviours (Heinicke and Carr, 2014).
In 2007, a review evaluated 67 studies focusing on behavioural intervention for problem behaviour only. They found most studies employed a multi-component approach whereby 2 or more interventions were combined. These interventions often involved modifying the environment and teaching new skills: for example, modifying structure, routine and task expectations to ensure success, giving choice and control, positive feedback, support and encouraging interactions, and teaching alternative communications. It was concluded that positive behavioral support is well-suited for problem behaviour in acquired brain injury.
In 2006, Ricciardi studied multi-component behaviour support plans for an adult with brain injury. The support plans covered 4 critical areas: 1) establish preventative strategies, 2) teach alternative behaviour, 3) reinforce positive behaviours, and 4) when problems occur, manage them therapeutically. The adult had numerous neuropsychological challenges, such as generalized muscle weakness, fatigue, incontinence, severe memory impairment (short and long term), poor concentration, sexual disinhibition, inflexible preoccupation with snacking, smoking, disinterest in most activities, excessively passive, and disruptive and aggressive behaviors. It was identified through antecedent (what happens just before the behaviour), behaviour (what is the behaviour observed?) and consequence (What happens exactly after the behaviour?) data, that challenging behaviour was functioned by escape and avoidance during tasks and low preference activities (e.g., too long on the same activity, activities we “know” he doesn’t like, and request to leave room denied). The interventions put in place to prevent behaviour involved re-engineering the environment. This involved adding visual activity schedules including programming activities, snacks, smoke and bathroom breaks; incorporating preferred activities within the schedule and offering choice of alternative activity when bored; and avoiding interrupting egress (i.e., leaving) by prompting an alternative (requesting).
In addition to preventative strategies, Ricciardi combined them with positive teaching strategies, such as praise and access to highly preferred activities (eating and smoking) for following the visual schedule, prompting alternatives when bored, and to teach returning to the schedule.
Stimulus fading and transfer of stimulus control has also been used as an intervention for reducing obscenity and aggression in a brain-injury adult, functioned by escaping demands (Pace, Ivancic, Jefferson, 1994). Stimulus fading involves removing the thing that triggers the behaviour (i.e., eliciting stimulus) and gradually fading it into the individual’s presence again. For example, the individual arrives at lunch time, eats lunch, then goes into library (preferred), then leaves after half an hour. Then add another half hour, and another, and so on. Gradually ease back into a full day.
Transfer of stimulus control occurs when behaviour initially controlled by one thing comes under the control of a different thing. For example, another staff person works side-by-side with a staff person that the individual acts appropriately with, then takes on more and more of the interactions, until the original staff is more or less in the background. As more hours are spent on site, more staff enter the staffing rotation until he’s working entirely with all staff.
Shaping is another behavioural intervention described in the research of brain injury. Shaping is the reinforcement of some approximation of the target behaviour (end goal). This means, any behaviour that resembles or is closer to the desired behaviour is reinforced until you get the behaviour you desired. Referring back to the adult with brain injury with toileting behaviours in Ricciardi’s (2006) study, shaping can be used for this. For example, steps can be encouraged for the individual to use the bathroom: looking into the bathroom, look in and move into the bathroom, move into bathroom and check pants, check pants, sit and try, sit and produce. The idea is to present the “demand” in a way that is unlikely to evoke the problem behavior. Following each step with reinforcement should recondition the individual with toilet = access to reinforcement.
Behavioural learning principles are also used to teach life skills in individuals with brain injury such as prompting/prompt fading (an entire multi-step, complex skill is taught in sequence, and success is ensured by verbal prompting) and response interruption and redirection (RIRD) (errors or interfering behaviors are managed by verbal interruption, and directing an appropriate action). A case example shows how these behavioural techniques helped an individual with a gastrostomy tube consume solid foods. The challenges involved overcoming habitual refusal “I don’t like it”, spitting out foods, and re-learning the sequence of bite, chew, swallow. The behavioural interventions involved adapting the environment by providing continuous 1:1 supervision throughout meals and talking to the individual, cutting food into bite-sized pieces and placing a drink near and encouraging small gulps using encouraging and gentle tones. Interactions during meals would involve encouraging small bites and to swallow before taking another bite, redirect attempts to spit out food by verbally encouraging them that they can do it, reminding them to swallow when noticing excessive chewing, encouraging them to try when they say they don’t like or want it, and praise bites and swallows.
There are many behavioural analytic interventions you can use for all types of behaviour, however, it is important that the intervention is trained at a high level to those who are implementing them. Behaviour analytic principles are also used to teach staff members to implement interventions effectively: this is known as behavioural skills training (i.e., checklist-based training or competency-based training). Behavioural skills training is a method that involves instruction, modelling, behavioural rehearsal and feedback to teach new skills. Comprehensive reviews suggest that systematic teaching is more effective than “learning through error”. Effective instructional procedures involve: minimizing errors (prompting/fading, graduated guidance and error correction procedures), explicit models (before starting a task or a specific step and during task), engagement strategies (meaningful goals, optimal level of challenge, explain/discuss the lesson and goal with the learner, positive interactions, support, encourage, praise, and act on signs of inattention, eyes off task, fatigue), and guided practice.
In addition to teaching how to implement interventions effectively, it is also important that behaviour plans are designed to reduce any errors and misunderstandings for the reader. When designing behaviour plans, it is recommended that antecedent strategies come before problem behavior to reduce the likelihood of problems behavior and to increase the likelihood of positive behaviors (Luiselli & Cameron, 1998). It is also important for technological terms to be minimized or avoided when possible. Simply using plain language and clear descriptions in the plan will reduce any future errors. In addition to language, avoid any that might encourage control, coercion or punishment. For example, “do not permit drink until she has consumed at least 50% of meal”, “Do not let her throw food away” and use clinically informed, sensitive language.
To review, there are far more applications of behavior analytic principles to support neurorehabilitation than many might realize!
by Lynette Davies, MSc, Board Certified Behaviour Analyst