Understanding the Role of a Behavior Analyst within an Interdisciplinary Treatment Team Working with Individuals with Traumatic Brain Injury

Transcription

1 Understanding the Role of a Behavior Analyst within an Interdisciplinary Treatment Team Working with Individuals with Traumatic Brain Injury Santa Clara Valley Brian Injury Conference 2012 Saturday February 25, :10 AM Platform 5 Presenters: Chris Schaub, MscEd, BCBA Christina Peters, MscEd, BCBA, CBIS

2 Common misperceptions about Behavior & Behavior Analysts Definition of behavior is limited to acting out. The client has a behavior problem and the BA s role is to fix their problem. The BA is the on-call crisis intervention person. Treatment can/should occur in isolation. Behavior Analysts disregard feelings, cognition, mood etc

3 The Role of the Behavior Analyst as a Team Member Work collaboratively with all team members, including those providing direct care to the client Support efforts of other clinicians through promoting understanding of behavior Conduct systematic observations, interviews and formal assessments (Functional Analysis/Assessment) Identify target behaviors and plan interventions. Establish and maintain data collection efforts Team Leader Guide overall treatment in a manner consistent with behavior analytic concepts & principles Prioritize and integrate treatment team efforts within behavior analytic framework Educate team members and other audiences, e.g. families, funders, etc about behavior Whenever possible seek to influence culture, policies, procedures, standards of practice within the organization

4 Subject Profile Severe Brain Injury- struck by a motor vehicle while working 44 years old at time of injury Funded through workers comp Medical Complexity- History of UTI s, C-Diff Bowel incontinence Dysphagia as well as more general food and fluid intake issues Significant Physical Impairment; Spastic quadraperesis; extensive contractures with tone and spasticity issues in ankles, hips Complex pain profile Completely dependent for all transfers and physical care Challenging Behavioral Presentation Agitation, restlessness, verbal aggression, physical aggression Constant yelling

5 Injured in April 2008 History Trauma care followed by Acute Rehabilitation Challenging acute rehabilitation candidate Eventually was unable/unwilling to work with multiple team members Transferred to Nursing home Behaviorally unstable Significant deterioration Family advocated for returned to Acute Rehabilitation Hospital for more intensive therapy Stabilized initially Due to ongoing issues with behavioral instability rehab was unable to meet goals and acute rehab sought to discharge Admitted to ReMed s STIRS (Short Term Intensive Rehabilitation Services) for Post-Acute Rehab in June 2009

6 Applied Behavior Analysis in Neurobehavioral Programming: Establish Medical Stability Promote Behavior Stability Develop Stable Activity Plan

7 Role of Behavior Analysis in Medical Stability Phase of Treatment Role of BA Create and disseminate Crisis Plan Use philosophy to set out a vision for team and family Identify and define target behaviors and Determine method and type of data collection Implement structured routine to promote stability and enable data analysis Prioritize behaviors and maintain appropriate expectations Key Issues & Events Admission & Stabilization Severe pain and spasticity Bowel & Bladder Incontinence Food & Fluid Input Issues Positioning Schedule Intense Verbal & Physical Aggression Resistance & Refusal Milieu disruption 1/10 Baclofen Pump placement 5/10 Valium Taper begins

8 Data Collection Tool MacroTracker

9 Frequency of Target Behaviors Observed Per Day 11/28/09-12/11/ Shouting Shaking Self Harm Frequency /28/ /29/ /30/ /1/ /2/ /3/ /4/ /5/2009 Interval 12/6/ /7/ /8/ /9/ /10/ /11/2009

10 Role of Behavior Analysis Behavior Stability phase of Treatment Role of BA Continue to guide team and family via philosophy. Refine data collection and employ data-based decision making for programming elements Conduct Preference Assessment Consider Functional Analysis and/or Assessment to refine hypotheses Identify Functional Classes and precursors for target behaviors (especially if high risk ) Employ procedure for one or more target behaviors (e.g. differential reinforcement, shaping, positive/negative reinforcement) Combine Extinction and NCR techniques to promote safety Key Issues & Events Established stable baseline data as medication trials conclude Identified target behaviors function Stabilized aggression and promoted follow through 12/10 First home visit 1/11 Hip surgery-tendon release procedure to reduce spasticity 4/11 Formal Functional Analysis 5/11 Formal programming based on findings of Functional Analysis.

11 Frequency of Target Behaviors Observed Per Day 2/28/11-3/14/11 Shouting Shaking Unsafe /28/2011 3/1/2011 3/2/2011 3/3/2011 3/4/2011 3/5/2011 3/6/2011 3/7/2011 3/8/2011 3/9/2011 3/10/2011 3/11/2011 3/12/2011 3/13/2011 3/14/2011 Frequency Date

12 Role of Behavior Analysis in the Stable Activity Plan Phase of Treatment Role of the BA Continue data-based decision making Continue to refine and work towards criteria for stability and safety Ensure Generalization and Maintenance of skills through specific programming and support Key Issues & Events 6/11 Fluid restriction begins secondary to SIADH 9/11 TURP Procedure Lamictal and Tegretol weaning secondary to SIADH concerns 11/11 Transitioned off visual regard and maintains safety/stability Home visits begin for holidays and some one day weekend visits

13 Frequency of Target Behaviors Observed Per Day 12/3/11-12/17/11 Shouting Shaking Unsafe Frequency /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/2011 Date 12/11/ /12/ /13/ /14/ /15/ /16/ /17/2011

14 Looking ahead, key points Recognize that Behavior is not just defined by acting out Behavior does not occur in isolation. Understand that Effective and efficient treatment requires the expertise of a highly trained professional. Treatment must be integrated across all team members. Explore integration of a Board Certified Behavior Analysts (BCBA) into your team. if unable to fully integrate this role, consider consultation.