Background:



CASE 1

Background:

Patient is a 17year old male status post severe TBI from ATV accident 5 months earlier. Neuroimaging revealed diffuse axonal injury in both frontal lobes, temporal lobes, and parietal lobes. He was nonverbal at the time of evaluation but could point to yes/no card to answer simple questions. When orientation was assessed this way, he was disoriented except to name and hometown. He used a wheel chair for ambulation but was dependent in locomotion. He was also dependent in all aspects of self care but was able to use his left hand to do gross motor tasks such as holding cones in occupational therapy. He was tall and muscular and required a two-person assist with all transfers. His parents were supportive and present throughout the day to accompany their son during all therapies and aspects of his medical care.

Complaint:

During behavioral management rounds, the patient’s OT and PT complained that the patient needed medication. They reported that the patient grabbed their breasts and buttocks during therapies. The SLP did not have this complaint. Nursing was not present and had not voiced this concern. Therapists also complained that the parents “just stood there” and did nothing to assist them in these moments.

Psychologist First Observation/Data Gathering Session:

Patient observed in joint physical and occupational co-therapy session. The patient was noted to attempt grabbing behavior only when working in close proximity (most of the time due to his physical status) to his young, female therapists.

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CASE 2

Background:

Patient is a 28 year-old male hospitalized for comprehensive rehabilitation for TBI approximately 2 years earlier. When discharged from acute hospitalization, he was sent home with minimal follow-up for problems such as severe spasticity. He received no PT, OT, or ST as an outpatient. Most of his days were spent in front of a TV at home. Upon readmission to rehabilitation, he was found to not give spontaneous speech and would answer some questions with verbal responses if persistently cued. He was oriented to his name, hometown, date of birth but gave his age incorrectly (age at time of injury). He was disoriented in all other spheres due to severe memory impairments. When asked about his reason for hospitalization, he did not know he was in a hospital. When asked about his impairments, he did not acknowledge any deficits including the inability to walk or functionally use his extremities (awareness impairments)

Complaint:

PT and OT reported that the patient attempted to strike therapists several times with his fists. He had significantly injured one of the OT technicians who was placed on medical leave due to injury to her hand. Nursing reported similar problems during transfers: the patient would become agitated but had not hit any of the nursing staff to date.

Psychologist First Observation/Data Gathering Session:

Pt was observed in PT in the main gym. The focal activity was stretching of his legs. During this activity, the pt would attempt to voice “STOP” when stretching began. When he did this, the therapist would respond “we have to stretch your legs.” Patient would again voice “STOP!” The therapist continued to stretch him and pt subsequently began to swing his arms in an attempt to strike the therapist. The therapist was clearly frustrated and displayed this in her tone of voice. The therapist responded that since he did this, he was not going to get to watch television that evening and he would have to go back to the nursing station immediately and miss therapy at that time. The patient was immediately brought back to the nursing station and not allowed to watch television that evening.

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CASE 3

Background:

Patient is an 18 year-old male hospitalized for comprehensive rehabilitation. Upon admission, he was ambulatory, nonverbal, and with flat affect. His Mississippi Aphasia Screening Test Score was 0/100 with a suspicion of global aphasia consistent with the site of his brain injury. He was noted to not follow single step verbal commands for any staff member. However, he would follow visual commands demonstrated to him. On occasion, he would pick up a telephone and say hello. He was also noted to hit buttons on the remote control when lying in bed. He did not interact with staff. He often held his head down when others tried to engage him. His GOAT score was -8 due to non- responding to orientation items or visual stimuli indicating choices for orientation items. His agitated behaviora scale score was 27 (high degree of motor restlessness and inattention). During his first few days on the unit, he was noted to not eat much on meal trays brought to his room. Later, he was found to have trouble manipulating objects consistent with an apraxic presentation that is also consistent with the site of his injury. Although he was physically capable of toileting independently, he would have accidents or would be noted to urinate in the trash can in his room.

Complaint:

Elopement In Progress

Psychologist First Observation/Data Gathering Session:

Pt was observed in the elevator lobby of the locked unit with security and staff surrounding the patient. He was yelling unintelligable phrases and backing into the wall. As staff stood around, he would hit the doors of the elevators but would not hit the call button. Although the elevators required a passcode (current month and date) to active the call button, an elevator opening on the floor would allow an exit. An elevator eventually opened and the patient got on the elevator. Staff held the elevator on the floor. Patient did not attempt to hit other floor buttons to complete an exit. He would pace the interior of the elevator and occassionally hit the walls. He never attempted to hit staff. When an alarm sounded indicating the elevator had been held on the floor too long, the patient got off the elevator and went back to his room. Security and floor staff backed off to not frighten the patient. When he got back to his room, a nursing assistant (on loan from another floor and who unfamiliar with the patient) was waiting for him. Psychologist followed him into his room and observed nursing assistant state in a frustrated tone “Are you going to cooperate with me now and let me take your vitals (while she standing with her hands on her hip).” The patient sat down on his bed and held his head down. He did not look at the nursing assistant. He did not cooperate with her vitals exam. Psychologist learned that this was the situation taking place prior to his elopement. He was not “cooperating” with vitals exam which led to increased frustration by the nursing assistant trying to finish her rounds.

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Answer Sheet

Please wait to read until designated time during talk!

Case 1:

Define Problem Behavior:

• Inappropriate sexual behaviors: grabbing of staff breasts and buttocks

Antecedents:

• OT & PT sessions during therapeutic exercises (sitting balance – using arm to grab cones, transfers, and other times when therapist in close proximity).

• When female staff were on his left side

• Upon interview with nursing staff, he would reportedly grab some of the female nurses during transfers.

• Upon interview with his mother, she reported no incidents of grabbing her but she walked in when he was masturbating in his room.

• Never grabbed mom, dad, or other male staff.

Consequences

• No reaction from parents.

• Therapists showed embarrassment (flushed face, nervous laughter), and told patient “no” in casual voice and continued with sessions.

Hypothesis 1:

Patient is showing dis-inhibition (poor impulse control) when presented with stimuli of sexual nature. His limited motor control allows him to grab when in close proximity. This is occurring in his two therapies in which he has close contact with OT & PT. Not happening in SLP because he sits at a desk when working with SLP. He reportedly has engaged in this behavior with female nursing staff during transfers (close proximity). Persons with severe TBI can exhibit poor behavioral control that is expressed with sexual gestures (verbal and nonverbal). This clinician’s experience is that it is common among young male TBI survivors and that it fades during the recovery process (typically in the first year) sometimes longer with the exception of two cases (for another discussion).

Treatment approach:

1) Involve and educate family about this symptom. Inform therapists that family were embarrassed and had no idea what to do in this situation. They were hoping the therapists would guide them in responding to the behavior. Discuss with both therapists and family that this behavior can be common and has nothing to do with who the patient was before his injury and that it is likely a transient symptom of his neurological injury (i.e., poor impulse control and suspected hypersexuality).

2) Adopt response prevention strategies. Antecedents are female staff in close proximity to his left side (good side). Plan was to ask dad to hold patient’s left hand when not being therapeutically addressed in “high risk” situations. Also have nursing teach dad (male) to do transfers at bedside. Mom was not strong enough since patient was of large physical stature. General strategy was to have patient use his left hand in activities that were incompatible with grabbing of female staff (i.e., holding dad’s hand; holding therapy devices, etc.).

3) If the behavior occurred, we planned to involve dad or mom in responding to the behavior in a “firm” tone of voice as a consequence and redirect patient to appropriate therapeutic tasks. Caution was taken to avoid embarrassing the patient in front of others. We asked therapists not to laugh or display behavior that could be perceived as reinforcing (he may have enjoyed that he made them laugh – even thought it was a nervous laugh). Have them also make a firm “no” response and redirect patient to therapeutic activities while avoiding embarrassing the patient which could escalate a situation.

Results:

Hypothesis 1 worked! Highlighting the importance of identifying antecedents, we prevented the behavior a majority of the time by having patient engage in a behavior incompatible with grabbing during high risk situations in therapy. Dad or male nursing staff handled all transfers throughout the day. Collectively, these are response prevention techniques since we prevented the behavior by accurate identification of antecedents. Over time, the TBI patient’s symptoms faded and inappropriate grabbing was no longer an issue.

Case 2:

Define Problem Behavior:

• Hitting

Antecedents:

• PT and OT sessions

• Stretching of spastic limbs

• Patient yelled “stop”

• Therapist ignored patient’s request to stop stretching him

Consequences

• Therapist used frustrated tone to react to patient’s behavior

• Stopped therapy session and taken to nursing station

• No television that evening

Hypothesis 1:

Patient is severely cognitively impaired (poor memory for new information thus is disoriented) and shows poor awareness for the nature of his deficits and the importance/relevance of therapy activities. His perception is that he is being hurt by someone and he wants to stop painful therapeutic activities. Prior to hitting episode observed, he did engage in “more appropriate” behaviors, yelling stop, that were “ignored” by the therapist.

Patient was never violent with nursing but yelled out loud during transfers. Due to the severe spasticity in his lower limbs, he likely was experiencing pain during nursing transfers. Transfers are brief, time-limited, activities. As such, the patient did not escalate to violent behavior to stop the painful activity (i.e., transfers) with nursing.

Treatment approach:

1) Educate therapist about patient’s cognitive status and poor awareness for his impairments and poor understanding of his therapy sessions. Ask therapist to “remind” patient of purpose of therapy session at start of each session and at beginning of new exercises in that session since he is likely to forget reason why he is engaging in therapy.

2) Educate therapist about importance of avoiding negative nonverbal communication in working with patient.

3) Educate therapist to be responsive (i.e., reinforce) to the patient’s appropriate behaviors of wanting to avoid the pain (i.e., verbal communication such as yelling “stop”) so that he does not escalate to hitting her to stop the painful activity. Tell her to stop the activity if he reports pain.

4) Discuss other strategies to help patient engage in therapeutic activities that are painful in nature. Consider a distraction technique. Have patient see a kitchen timer and choose the duration of the painful stretching activity (e.g., 5 seconds). Use that time interval regardless for the first activity. Have the patient count and look at the timer during the painful activity. For the next set, ask patient to increase the time any amount as long as it is longer than the first time interval (e.g., 6 seconds). Allow patient that level of control so that they will engage in necessary therapeutic activities.

5) Educate therapist that stopping her therapy session and placing patient at nurses’s station only reinforced his hitting behavior since he wanted to avoid painful activities. He will likely go directly to hitting behaviors next time since it was effective in stopping the painful activity moreso than asking her by yelling “stop.”

6) Educate therapist that punishments that are remote in time to the problem behavior are less effective / ineffective. This patient’s cognitive status was such that the did not understand that his inability to watch TV that evening was associated with his hitting his therapist several hours earlier in the day.

7) Ask therapist to engage in non-painful activities with the patient so that she avoids always being associated with pain.

Results:

Hypothesis 1 worked; however, the therapist was already experiencing negative emotion towards the patient that was challenging for her to overcome. She had little experience in dealing with this type of emotional reaction to her patients in her formal training. She and I discussed this at length. I attended therapy sessions with her to model reinforcement of desirable behaviors (i.e., verbal praise) and demonstrate use of distraction techniques. She developed some co-treatment sessions with SLP so that the patient was engaged in distracting tasks during some of her therapy sessions. As the patient’s spasticity improved with serial stretching and casting, he reported less pain during these activities. No further incidents of violence occurred in therapy and the yelling stopped with nursing.

Case 3:

Define Problem Behavior:

• Elopement

• “Uncooperative”

SituationalAntecedents:

• Vitals Exam at bedside

• Unfamiliar staff

• Verbal instruction used to comply with vitals assessment

• Frustration in voice of clinical provider

Patient Antecedents:

• Receptive language problem (poor comprehension of verbal statements made to him secondary to left FTP hemisphere injury)

• Apraxia – inability to use objects accurately and consistently – note that automatic behaviors are most perserved (picking up phone and saying hello; holding remote control – for some). Many staff observed him pick up the phone when it rang or hit buttons on remote and assumed he was more capable of other complex motor behaviors. His apraxia was more pronounced in tasks requiring use of utensils (incomplete meals), going to urinal accurately and consistently, using elevator buttons, knowing how to call the elevator etc.

• Acute confusion (delirium or post-traumatic amnesia).

• Lability – more pronounced in delirium/confusion and likely intensified his frustrated response to vitals examination – also observed with frontal lobe lesions.

Consequences of his being uncooperative

• Patient escalated quickly in situation where he may have perceived someone being upset with him. Although he did not understand the content of speech (aphasia), the prat of the brain that interprets nonverbal communication was intact. He likely understood the nonverbals that staff communicated to him.

• Potential elopement

• His elopement ceased when the elevator noise was uncomfortable to him and he went back to his room.

Hypothesis 1:

Patient likely did not understand the instructions of nursing when asking him to cooperate with vitals exam. He escalated due to nonverbal communication style of staff suggesting anger and frustration.

Treatment approach:

1) Involve and educate all staff about patient’s cognitive deficits.

2) Adopt response prevention strategies. Help staff with communication style and implementation of non-verbal communication with him. For example, using a calm voice and letting patient see staff face when interacting with him helped to get his attention. Use of gestures while speaking to him calmly helped to get his cooperation.

3) Educate staff about cognitive and behavioral deficits of this patient and provide strategies for maximizing patient cooperation given the patient’s unique neurologic profile. Ask staff to pass information along from shift-to -shift.

Results:

Hypothesis 1 worked! Staff implemented strategies recommended with patient. Patient continued to make progress and resolved from his acute confusional state with no further episodes of elopement. [pic]

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What happened

Reaction from others

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“C”

Consequences

“B”

Behavior

“A”

Antecedents

What happened

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“C”

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“B”

Behavior

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What happened

Reaction from others

Get something

Avoid something

Other changes

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Frequency

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“B”

Behavior

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“C”

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“B”

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“A”

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Time of Day

“C”

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“B”

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“A”

Antecedents

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