a neurobehavioural rehabilitation approach to the ......27 nbr in practice • promotes and...

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A Neurobehavioural Rehabilitation Approach to the Management of

Post-ABI Aggressive Behaviour Disorders

Professor Nick Alderman Clinical Director, Neurobehavioural Rehabilitation Services

Elysium Neurological

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In this session we will…

• Set the context – prevalence of aggression after ABI

• Aggression in NbR services

• Reduction of aggression – as a consequence of the therapeutic culture within NbR

• Reduction of aggression – as a consequence of additional individual interventions

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Context of ever changing moral, ethical and legal back drop

• Mental Health Act • Mental Capacity Act • DoLS • Political decrees • Society attitudes • Rights of the individual • Growing culture of litigiousness?

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Long-term Outcome

In studies conducted over many years, challenging behaviours have been recognized as

posing a greater long-term impediment to community integration after TBI than physical

disabilities

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Fleminger, Greenwood & Oliver (2003)

“Of the many psychiatric symptoms that may result from brain injury, agitation and/or aggression are often the most

troublesome.”

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Aggression after ABI

Baguley, Cooper & Felmingham (2006)

• Followed up TBI survivors (moderate – severe injury) 6, 24 and 60 months post-injury in Australia

• 25% demonstrated significant levels of aggression at each of these times, as defined by the researchers

• Concluded it was common and long-term following of TBI

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Kelly, Brown, Todd & Kremer (2008)

• Investigated challenging behaviour profiles of people with ABI in the community

• Aggression prolific

86% verbally aggressive 41% aggressive to people 35% aggressive to objects

• Aggression was a long-term consequence of ABI (mean TSI 10 yrs, max 41 yrs)

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Tateno, Jorge & Robinson (2003)

• Literature review

• Prevalence varied 11 – 96% studies

• In their study, 34% had engaged in significant aggressive behaviour within 6 months after injury, as defined by the researchers

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Variability in outcome data, uncertainty about proportion of people with ABI for whom

aggressive behaviour is an issue…

Tateno et al.(2003) Found prevalence varied

11-96% studies

Confounded by inconsistent use of different terminology and methodologies

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Irritability

Agitation

Anger

Aggression

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Is Aggression after ABI Talked Up Too Much??

From Baguley, Cooper & Felmingham (2006)

From Baguley, Cooper & Felmingham (2006)

4% 19%

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Aggression in NbR Services

How Characteristic is Aggressive Behaviour

Typical of People Referred to Neurobehavioural

Services?

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Aggression in NbR Services Percentage Admissions to NbR Services Whose SASNOS

Domain Scores Are <1SD from Neurologically Healthy Norms

Perc

enta

ge

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Aggressive behaviour exhibited by 108

participants in NbR over a 14 day period

5548 episodes

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Prevalence of Aggression in NbR Services

Source: Alderman, N., Major, G. and Brooks, J. (2016). What can structured professional judgement tools contribute to management of neurobehavioural disability? Predictive validity of the Short-Term Assessment of Risk and Treatability (START) in acquired brain injury. Neuropsychological Rehabilitation.

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Aggression & NbR Services

• Neurobehavioural services are asked to manage very high levels of aggression

• Expert assessment of NBD including aggression

• Capability to manage and reduce aggression

• Structures and organisation promote rich, positive therapeutic climate that encourages success

• Therapeutic milieu acts as prosthetic that circumvents some neurocognitive and social drivers of aggression

• Comprehensive evidence base

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Outcomes from NbR

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Outcomes from NbR

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Aggregate Aggression Score

Mea

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core

First Assess

Last Assess

Discharged

Reduction in Aggression on the OAS-MNR

• Percentage reduction in the AAS was 75.6% (61.7% previous year)

• Percentage reduction for discharged cases was just under 90%

• Remains superior to the benchmark figure of 53.2% for another major NbR provider

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Aggression & NbR Services

Why are NbR services able to manage and reduce aggression?

Suggest rehab participants require either:

1. A ‘standard’ NbR programme is sufficient…

…or…

2. A ‘standard’ NbR programme *plus* additional specialist intervention is required

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Neurobehavioural Rehabilitation

What is ‘Neurobehavioural Rehabilitation’?

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCMLpg6yv-ccCFQVUFAodSF4Fvg&url=http://www.ukfast.co.uk/blog/2012/08/28/backtobasics-what-is-capacity-threshold-monitoring/&psig=AFQjCNEEoMWjt7HkkBuCKWAS39vIpMb6gw&ust=1442417828830052

NEUROBEHAVIOURAL REHABILITATION An approach inspired by Gavin Tennent and

pioneered in the UK by Peter Eames & Rodger Wood

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Neurobehavioural Rehabilitation

Neurobehavioural rehabilitation attempts to alleviate social handicap arising from

neurobehavioural disability

Delivered in context that understands ABI, determines brain-behaviour

relationships, and intervenes to maximise personal autonomy

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Characteristics of NbR

• Post-acute

• Neuropsychological model of rehabilitation

• Slow-stream rehabilitation

• Behaviour management capability

• Structured environment (incorporating systems of feedback & reinforcement)

• Transdisciplinary Team approach (TDT)

• Behaviourally-defined rehabilitation goals

• Community-based training

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NbR in Practice

1. The (re)acquisition of functional and social skills

2. Spontaneous and adaptive performance of these skills in the context of social behaviour

Social handicap arising from neurobehavioural disability improved through

Learning theory is central to neurobehavioural rehabilitation as a means of understanding handicap and managing symptoms

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NbR in Practice

• Promotes and underpins a highly structured approach.

• Framework to understand NBD symptoms, and plan and deliver rehabilitation.

• Therapy interventions in every discipline draw heavily from learning theory, especially operant conditioning & procedural learning

• Practitioners need to have knowledge of these methods and supervision to devise effective rehabilitation interventions

• NbR programmes therefore typically led by clinical neuropsychologists rather than medical doctors

Learning Theory Underpins NbR

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NbR in Practice – applying learning theory

Procedural learning

Errorless learning

Antecedent control

Contingency management

Modelling

Shaping, chaining

Mediating effects of neurocognitive impairment

Well managed behavioural interventions:

• Change staff behaviour

• Encourage positive interaction

• Enable a consistent team approach

• Help develop a positive social climate

A positive social climate promotes therapeutic relationships and is highly predictive of good treatment outcomes

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NbR in Practice

The Transdisciplinary Team (TDT)

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The Transdisciplinary Team (TDT)

NbR in Practice

• Therapy does is not limited to timetabled sessions, with qualified therapists during the nine-to-five working day

• Interventions are continually applied

• Effort and achievements are reinforced through interaction with every member of the team

• The whole team are empowered to regard their role as that of agent for behaviour change

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NbR in Practice

The overall effect of these structures is creation of a ‘prosthetic environment’ within which a person’s awareness and capacity for social learning are optimised

(Wood & Worthington, 2001)

• Increases awareness

• Improves motivation

• Shapes behavioural responses into acceptable forms

(Wood, 1990)

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Aggression Reduction in NbR

Programmed feedback may circumvent monitoring difficulties that drive behaviour problems

“Disinhibition is characterised by inadequate self-monitoring resulting in impulsive and

inappropriate social behaviour” (Becker & Vakil, 1993)

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Baseline Evening Feedback Half-hour Feedback

Effect of Scheduled Feedback on Inappropriate Interaction with Males in a 19 yr Old Female with Severe CHI

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Creation of prosthetic environment that circumvents cognitive and

other problems that drive/maintain DES behaviour problems

May be one reason why some aggressive behaviour disorders

quickly resolve following admission to NbR or implementation of a

system that emphasises feedback

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Reduction of Overt Aggression Whilst Increasing Rehabilitation Expectations in NbR

Frequency aggression (OAS-MNR)

Expectations (NES)

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When a ‘Standard’ NbR Programme is not enough…

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NbR in Practice

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NbR in Practice

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Consider the morality of behaviour

change

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What constitutes ABI ‘challenging behaviour’?

• Is the behaviour ‘challenging’?

• Is it ‘right’ to intervene?

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Behaviour judged by many yardsticks… …e.g. society norms vs. individual beliefs

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Aggression that is ‘acceptable’ vs. ‘not acceptable’ dependent on many factors:

• Age & gender

• Context

• Applicable norms

• Status of aggressor

• Perception and values of perceiver

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• Increases vulnerability

• Limits/delays access to community resources

Behaviours (inc. aggression) whose presence:

• Constrains participation in post-acute neurorehabilitation leading to failure to exploit and attain the persons full potential for recovery

(Eames & Wood, 1985; Wood, 1987; Alderman, 2001)

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NbR in Practice

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NbR in Practice

Intervention Must be Preceded by Assessment

• Determine factors driving behaviour disorder

• ABI knowledge essential to understand these factors

• Knowledge of ABI, leaning theory and especially functional analysis provides a means of understanding symptoms of NBD

• Provides individualised approach

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Why can aggressive behaviour be a consequence of ABI?

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Aggression After ABI

• Neurologically mediated

Orbitofrontal cortex and its connections, deprives cognitive functions of ability to suppress emotional reactions – has clear antecedents

Episodic dyscontrol syndrome (EDS) – trivial antecedents, aggression out of proportion

• Exacerbation Negative Premorbid Traits

Impulsive, inflexible, poorly developed self-control pre-injury, more evident post-injury

Miller (1994)

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“Hey, so I get drunk and start fights - what do you expect?

I was a mean mother ****** before my accident, and my brain damage has made me one biogeneticlly dangerous dude.”

(stated with a grin)

From Miller (1990):

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Aggression After ABI

• Neurocognitive impairment

executive function disorders especially

lack of ‘error awareness’ results in frustration and aggression

• Environmental factors

interaction with carers and clinicians

• Post-injury learning

aggression serves avoidance/escape function

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cognitive impairment

premorbid traits

neuropsychiatric

poor adjustment

poor insight

learned response

environment

ABI Aggression

organic

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Assessment of ABI Aggression

Functional Assessment of Behaviour

Determining reasons that drive behaviour using conceptual framework provided by operant conditioning:

• Identify relationship of behaviour with environment

• Setting events?

• Antecedents that evoke behaviour?

• Reinforcing consequences that maintain it?

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• Whilst there are many measures of aggression, the OAS-MNR was specifically validated for use with ABI and NbR

• The OAS-MNR has known psychometric properties (Alderman, Knight & Morgan, 1997; Giles and Mohr, 2007)

cross reference

category x

severity

behavioural

descriptors

four levels

severity

categories

OAS-MNR

There are 18 antecedents

numbered from 1 -25

1-3 comprise possible ‘setting events’

11-25 are events

observed immediately

before behaviour -

‘antecedents’

for example

‘1’ – ‘structured activity’

for example

‘21’ – ‘given item’

for example

‘M’ – ‘physical distraction’

There are 14 categories for

recording interventions used to

respond to/manage behaviour

Each is coded with a letter

ranging from A - N

A charity leading innovation in mental health

11/6

11/6

11/6

11/6

11/6

10:25 CK 11 VA1 A 10:30 22 PP2 L

10:36

10:50

11:00

16 PO3 D

23 VA3 A 24 VA1 A

CK

CK

CK

CK

Nick Alderman

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Assessment of NbR Aggression

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Aggression in NbR Services 73

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Rehab Sessions Other Times Verbal, 70

Others, 8

Objects,

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Self, 2

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mild moderate severe very severe

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verbal prompt verbal guidance agitated/distressed

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talking to patient

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B’line Intervention

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NbR in Practice

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Case Formulation

A hypothesis about the causes, precipitants, and maintaining influences

of a person's psychological, interpersonal, and behavioural problems.

This hypothesis drives intervention.

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Formulation

Draws on assessment data and information from multiple sources:

• Neuropsychological Assessment

• Neuropsychiatric Assessment

• Functional Assessments

• Informants

• History

• ABI Literature

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Formulation

Effect of Both Situational and Individual Characteristics on Aggressive Behaviour

Do these interact?

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Formulation

Aggression may be function of complex interactions between individual and situational variables

severe neurobehavioural

disability

more structured activity

verbal prompt

+ x = frequent aggression

Predictable, planned intervention possible, more risks may be taken in rehab

(Alderman, 2007)

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Formulation

Aggression may be function of complex interactions between individual and situational variables

x =

language impairment

severe neurobehavioural

disability

+

less structured activity

no overt antecedent

+

most frequent aggression

most severe aggression

most intrusive methods to

manage

Unpredictable, more reactive management, greater challenge to rehab services

(Alderman, 2007)

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NbR in Practice

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Intervention

learning theory operant

conditioning

principles that influence learning

positive reinforcement

specific techniques and procedures

DRI, DRL, DRO

treatment programme intervention (care plan)

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Intervention

• Contingency Management (Rodger Wood, Peter Eames, Nick Alderman)

Vs. (??)

• Positive Behaviour Support (Mark Ylvisaker, Tim Feeney, Gordon Muir-Giles)

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Intervention

Positive Behaviour Support

• Systematic gathering of relevant information

• Conducting a functional assessment of behaviour

• Highlights involvement of the person concerned

• Designing support plans (proactive strategies, early

warning signs, reactive strategies, managing the

aftermath)

• Implementation and ongoing evaluation

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Intervention

Combination of methods is ideally suited to meeting the complex needs of people with ABI

Multicomponent Interventions are the Norm

‘Example of a PBS Approach’

Rothwell, LaVigna & Willis (1999)

Actually a multicomponent intervention employing: functional assessment; positive programming;

environmental modification; behavioural contingencies; & reactive strategies

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Differential Reinforcement Procedures

NbR Services have a culture in which:

• Desirable behaviour is reinforced at *every* opportunity

• Undesirable behaviour is downplayed as much as possible (TOOTS)

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Positive Reinforcement

STIMULUS BEHAVIOUR CONSEQUENCES

increased probability will

occur again

Ensuring a pleasant consequence increases the likelihood the same behaviour will occur again in the future

If frequency/duration of target behaviour subsequently increases, it has been positively reinforced.

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Differential Reinforcement can be very useful in the management of ABI aggressive

behaviour disorders

Differential Reinforcement of...

• Low rates of responding (DRL)

• Incompatible behaviour (DRI) • Other behaviour (DRO)

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Differential Reinforcement of Incompatible Behaviour

(DRI)

Substitute a Behaviour

Reinforcement delivered when engages in behaviour incompatible with target behaviour

Core characteristic of NbR Environment

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Case LM Alderman, Davies, Jones & McDonnel (1999)

• ‘Very severe’ TBI through RTA

• History frequent, severe physical assaults

• Poor memory, impaired executive functions, significant expression/comprehension difficulties

• 72% physical assaults, 60% ‘severe’

• 66% followed attempts to engage in rehabilitation (verbal prompts, guidance, feedback)

• 15 minute DRI programme, including feedback, throughout the day

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NbR in Practice

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Evaluation, Generalisation & Maintenance

Evaluation

• Continuous evaluation within behavioural approach

• Monitoring of data

• Online adjustments to maximise gains

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NbR in Practice

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Differential Reinforcement of Low Rates of Behaviour

(DRL)

Reduce a Behaviour

Reinforcement delivered when target behaviour is performed less often

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• Define and measure target behaviour

• Collaborate with participant of intervention

• Set target low to ensure success from onset

• Increase expectations whilst maintaining success

• Reduce target to lowest rate possible, ideally move to fixed interval DRI with zero target & fade out

Differential Reinforcement of Low Rates of Responding (DRL)

• Or maintain minimum structure that supports participant in long-term

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b’line 50> 40> 30> 20> 10> 5> 0

5 d

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5 day block

FS: reduction in aggressive outbursts during hygiene routine using DRL

(Alderman & Knight, 1997)

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Case JH Watson, Rutterford, Shortland, Williamson & Alderman (2001)

DRL Intervention

• 4 opportunities to earn a star throughout day

• Earned if did not exceed target of being aggressive (initially) >18, VA2 or above

• Feedback about programme and performance at end of each interval

• Rehab team played down response when aggressive

• Stars exchanged for items from reinforcement menu at end of day or banked for more substantial reward

• OAS-MNR - 200 episodes, 4-55 p/day

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• Challenging behaviour previously reinforced in settings where people routinely ignored

• Inappropriate behaviour/inability to acquire new skills are function of poor monitoring

Reinforcement programmes improve monitoring by creating systems that provide participants with systematic feedback about performance that enables learning

Particularly relevant when:

Reinforcement programmes reverse these contingencies by compelling carers to engage in positive ways with participants, creating positive relationships

• Enriched environments that change behaviour

• Create positive social climate

• Promote therapeutic relationships

• Encourage new learning, skill acquisition

• Promote independence, increased autonomy

“…giving people more choice, control, and

freedom as they progress.”

Wood & Alderman (2011)

NbR Services Reduce Aggression

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Gladstone House, Stoke-On-Trent

NbR pathway to be created over 3 floors:

• Ground floor Acute neurobehavioural rehabilitation

Create new NbR services that set the bar re quality, reputation, cost effectiveness and outcomes

• First floor Mainstream neurobehavioural rehabilitation • Second floor Supported & independent living

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Thanks for Listening!

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Potentially Useful References Alderman, N., Knight, C. and Brooks, J. (in press). Therapy for acquired brain injury. In A.Beech, A.J.Carter, R.Mann and P.Rotshtein (Eds.). The Wiley handbook of forensic neuroscience. John Wiley & Sons, Ltd.

Alderman, N., Wood, R.Ll. and Worthington, A. (in press). Environmental and Behavioral Management. In J.M. Silver, T.W. McAllister and D.B. Arciniegas (Eds.). Textbook of Traumatic Brain Injury (3rd edition). American Psychiatric Publishing Inc.

Alderman, N. (2017). Interventions for Challenging Behaviour. In T.McMillan and R.L.Wood (Eds.). Neurobehavioural Disability and Social handicap Following Traumatic Brain Injury (2nd edition). Psychology Press, Routledge.

Alderman, N. and Knight, C. (2017). Managing disorders of social and behavioural control and disorders of apathy. In B.A.Wilson, C. van Heugten, J.Winegardner and T.Ownsworth (Eds.). The International Handbook of Neuropsychological Rehabilitation. Psychology Press.

Alderman, N. (2015). Acquired brain injury, trauma and aggression. In G.Dickens, M.Picchioni and P.Sugarman (Eds.) Handbook of specialist secure inpatient mental healthcare. London: The Royal College of Psychiatrists.

Alderman, N., Knight, C. and Brooks, J. (2013). Rehabilitation approaches to the management of aggressive behaviour disorders after acquired brain injury. Brain Impairment (Special Issue: state of the art reviews on mental health in traumatic brain injury), 14, 5-20.

Alderman, N. and Wood, R.Ll. (2013). Neurobehavioural approaches to the rehabilitation of challenging behaviour. NeuroRehabilitation, 32, 761-770.

Wood, R.Ll. and Alderman, N. (2011). Applications of operant learning theory to the management of challenging behaviour after traumatic brain injury. Journal of Head Trauma Rehabilitation, 26, 202-211.

Alderman, N., Davies, J.A., Jones, C. and McDonnell, P. (1999). Reduction of severe aggressive behaviour in acquired brain injury: case studies illustrating clinical use of the OAS-MNR in the management of challenging behaviours. Brain Injury, 13, 669-704.

Alderman, N. and Knight, C. (1997). The effectiveness of DRL in the management and treatment of severe behaviour disorders following brain injury. Brain Injury, 11, 79-101.

Watson, C., Rutterford, N., Shortland, D., Williamson, N. and Alderman, N. (2001). Reduction of chronic aggressive behaviour ten years after brain injury. Brain Injury, 15, 1003-1015.

a neurobehavioural rehabilitation approach to the ......27 nbr in practice • promotes and...

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