Principles of Behavioural Treatment in

Aquired Brain Injury

Professorial Tutorial
Dr Sebastian Theilhaber from 11/12/2007
With particular support through Jo DuBuisson (Psychologist/BDU)

Introduction

Behavioural treatment derives from Behaviourism, which has been called a “theory”, “school / movement of / in
psychology” [1,2], a “philosophy” [3] as well as an “attitude”, even “doctrine” [3] or “the only consistent and logical
functionalism” (as in: functional psychology) [4].

Acquired brain injury on the other hand, one might assume, will be something with a secured definition, which is,
to a surprisingly large degree, not the case.

Although we seem to be dealing with two constructs of somewhat diffuse definition, we will see it may not matter
too much in practice.

Definition of ABI / TBI

• Aquired brain injury is, depending on the source, traumatic, as in: traumatic for the brain, or referring to the
mechanism of injury. The use is not consistent and there does not seem to be a universally aggreed
definition.
• In Australia commonly used definitions are:
1. “Acquired brain injury (ABI) refers to any type of brain damage that occurs after birth.” [5], and
2. “Brain injury includes a complex group of medical and surgical problems that are caused by trauma to
the head.” [6]
This leads to inconsistent exclusion / inclusion of pathologic entities such as MS, Alzheimer, CVA, intracerebral
bleeding secondary to ruptured aneurism, Huntington etc.

However, for the sake of the purpose of our tutorial, the follwoning simplification might be allowed:
• Primary Injury [7]:
1. Direct impact and damage
2. Acelleration-/decelaration injury (shear-, tensile- and compressive-strains, causing intracranial
hematoma, diffuse vascular injury, or injury to cranial nerves)
3. Diffuse axonal injury (DAI, microscopic axonal damage, often not visible on imaging studies, caused by
rotational acceleration), which seems poorly understood but appears to be quite significant.
• Secundary Injury [7]:
Whithin hours or days after the event as impairment of cerebral blood flow, resulting in:
1. local edema,

1 [Merriam Webster Medical Dictionary Online] “behaviorism”

2 [The Internet Encyclopedia of Philosophy] “Behaviorism”
3 [Stanford Encyclopedia of Philosophy] “Behaviorism”
4 [Psychological Review, 20, 1913] “Psychology as the Behaviorist Views it”, J B Watson
5 [Better Health Channel] “Acquired brain injury”
6 [Brain Foundation Australia] “Acquired Brain Injury”
7 [emedicine] “Management and Staging of Traumatic Brain Injury”, Percival H Pangilinan

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 2. hemorrhage, or
3. increased intracranial pressure,
4. inflammatory response.
This may cause cellular ion pumps to fail, the excessive release of glutamate and aspartate, free radical
formation, proteolysis, and lipid peroxidation, all of which are believed to to cause neuronal death.

Classification- and prediciton-tools for ABI / TBI

• GCS:

• The GCS is the most widely used tool to grade the severity of it. GCS scores between 13 and 15 define mild
brain injury, whereas scores between 9 and 12 define moderate brain injury, and scores between 3 and 8
define severe brain injury . [8]

• The duration of loss of consciousness (LOC):

• PTA (Post traumatic amnesia): Period that elapses between the time of injury and the restoration of
continuous memory for day to day events, which clearly relates to the GCS and is often characterized by:
• Confused speech
• Pseudo-psychotic symptoms
• Perseveration
• Elated mood

8 [Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 8th Edition] “Neuropsychiatric Aspects of Traumatic Brain Injury”, pg 391

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 The PTA is defined as [9]:
PTA < 1hour mild injury

PTA 1-24 hours moderate injury

PTA 1-7 days severe injury

PTA > 7 days very severe injury

• “Westmead” and “GOAT” (Galveston Orientation and Amnesia Test) [ 10], which are both short MSE's
designed to assess orientation and amnesia, at least once a day and Westmead being the preferred
instrument.
• GOAT

Instructions: Can be administered Daily. Score of 78 or more on three consecutive occasions is considered to
indicate that patient is out of post-traumatic amnesia (PTA).

• PTA is believed to have ended, where tests are being scored accordingly or disorientation and amnesia
persists beyond six months, after which coma is unlikely to remit

9 [Russel]
10 [Zafonte 1997]

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 Definition of Behaviourism

In its more radical form, behaviorism is committed to the following claims [3]:
1. Psychology is the science of behavior, not of mind.
2. Behavior can be described and explained without making reference to mental events or internal
psychological processes and the sources of behavior are external, not internal.
3. Mental terms or concepts deployed in psychology describing or explaining behavior, should either be
eliminated and replaced by behavioral terms or they can and should be translated or paraphrased into
behavioral concepts.

In less radical terms, it can be described as the theoretical concept of psychology, assuming that it can be
investigated through behaviour with scientific methods and that it is the only valid measurement of psychological
processes.

Historical Aspects of Behaviourism

The history of Behaviorism can be divided into the schools of Classical- and Operant Conditioning.
The earlier "Classical Conditioning" school studied stimuli and responses to them, the later "Operant
Conditioning" school noted the importantance to attend to the consequence following the response.
Both schools are associated with the following personalities, a list which is by no means complete:

Classical Conditioning
• Ivan Pavlov
• John B Watson
• Edwin Ray Guthrie
• Albert Bandura
(14/09/1849 – 27/02/1936)
(09/01/1878 – 25/09/1958)
(09/01/1886 – 23/04/1959)
(*04/121925)

Operant Conditioning
• Edward Lee Thorndike
• Burrhus Frederic Skinner
• Clark Leonard Hull
• Ole Ivar Lovass
(31/08/1874 – 09/081949)
(20/03/1904 – 18/08/1990)
(1884 -1952)
(*?)

Ivan Petrovich Pavlov (Иван Петрович Павлов) was a Russian physiologist,

psychologist, and physician, who was awarded the “Nobel Prize in Physiology or
Medicine” in 1904 for research of the digestive system.
Pavlov noticed that food (unconditioned stimulus) triggered salivation (unconditioned
response) in his laboratory dogs. He also noted that the dogs salivated before the
standard feeding time, which perplexed him as there was no food present to be
digested. To investigate this "psychic secretion" phenomenon, he "paired" the ringing
of a bell (a neutral stimulus) with the presentation of the food. After about 10-20
"trials" the formerly neutral stimulus of the bell, activated salivation even when no
food was presented. The neutral stimulus became a conditioned stimulus that
activated salivation (now referred to as conditioned response).
He could also demonstrate, that several trials of ringing the bell with no presentation
of the food, the salivation (conditioned response) disappeared. The salivation
behavior at the stimulus of the bell also extinguished if the time period between the
bell and the presentation of the food was too great.
Although his experiments were carried out in the 1890s and 1900s, and were known to western scientists through
translations of individual accounts, they first became fully available in English in a book published in 1927.
[Source/picture]

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John Broadus Watson
Watson is the often referred to as "father" of behaviorism due to his soon-to-
be-famous article from 1913 "Psychology as the behaviorist views it".
He is known for having claimed - after his studies with “Albert” [11] - that he
could take any 12 healthy infants and, by applying behavioral techniques,
create whatever kind of person he desired
The reflex studies of Ivan Mikhailovich Sechenov (1829-1905) and Vladimir
Bekhterev (1857-1927) and Ivan Pavlov were particularly influential.
Watson favoured four assumptions involving behavioral radicalism:
Evolutionary Continuism: The laws of behavior applied to both humans and
animals, which is why we can study animals as simple models of complex
human responses, a notion widely refused by psychologists of his time.
Reductionism: All behaviors can be linked to physiology. Meaning that we are
biological organisms responding to outside influences.
Determinism: We don't act freely but respond in a programmed way to outside
stimuli.
Empiricism: Psychology should involve the study of observable behavior and
not introspection or self analysis.
[Source/picture]

Edwin Guthrie
Guthrie developed the principle of "all or none" learning (one either displays a response or doesn't in the
presence of a stimulus). He believed that individuals forget or lose a previous response to a stimulus because a
new behavior is found to be more beneficial, and the inhibition system allows only one response to occur to a
stimulus. He believed that disordered behavior was due to responses competing to occur to a particular stimulus,
thus causing stress and confusion.
Guthrie also described "one trial learning", pointing out that some new skills (responses) can be adopted
(learned) after doing it only once.

Albert Bandura
Bandura pointed out that for some learning (display) of new behaviors, not even
one trial is needed. Sometimes people observe another engaging in an action they
don't yet display, and then perform that behavior well on the first attempt.
In a famous experiment, children watched an adult enter a preschool classroom,
walk over to a table, pick up a hammer, and hit a large inflatable doll that had a
weighted bottom (so that the doll would return to an upright position after being
struck). The adult then left and the child who had been watching was allowed into
the room and was found to go directly to the doll to hit it with the hammer.
A new behavior was being displayed even though there had been no coaching or
practice. Later studies found that the characteristics of the model (the person
demonstrating the behavior) had an effect on the chances of the behavior being
emulated. High status (admired) models and those who were reinforced for their
behavior were most likely to have their response modeled.
Aggressive behavior was more likely to be modeled than non-aggressive behavior.
Professor Bandura continues to research and teach at Stanford University.

[Source/picture]

11 During the experiment, Albert was presented with a rat (stimuli) that then brought about the play response ("love" as is in contact with a
warm, fuzzy, moving animal). Then the investigator would walk up behind Albert and stuck a metal bar with a hammer, creating a loud and
frightening sound. After seven of those "pairings", Albert showed a fear reaction (crying) at the presentation of the original stimuli (a white
rat). This fear response "generalized" to new stimuli as Albert began to show fear when things similar to the fuzzy lab rat were presented.
This fear response extinguished after about a month of no loud sounds being made when lab rats were present.

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 Burrhus Frederic Skinner
Skinner is likely to be the most influencial
behavioral psychologist of all times and the
“Edgar Pierce”-Professor of Psychology at
Harvard University from 1958 until retirement in
1974.
He is known as the "father" of operant
conditioning and founder of “radical
behaviorism”, rejecting the reductionistic
construct of stimulus and mandatory reflex.
He discovered that whether a response to a
stimulus continues to occur depends on the
consequence that follows that behavior.
He discovered different "schedules of reinforcement", and formed the concept of
"shaping" ("the method of successive approximations”). He decribed the concept
of “aversive stimuli” and “behavior modification” (Extinguish an undesirable
behavior by removing the reinforcer and replace it with a desirable behavior by
reinforcement). A variation is the “token-economy” (primarily in institutions such
as BDU).
Skinner had started his career as an English major, writing poems and short stories and became a very
productive author and researcher, publishing 21 books and 180 articles and he never stoped inventing various
techniques and construction for his studies well into his higher age.
[Source/picture]

Edward Thorndike
Thorndike is considered to be the originator of reinforcement theory and the "father"
of educational psychology. He spent nearly his entire career at Teachers College,
Columbia University and described several principles regarding the effect of
consequences upon behavior.
His "law of effect" stated that the strength of the connection between a stimuli and a
response is an effect or result of the consequence that follows the behavior.
His "law of readiness" stated that an individual's physiology effects the influence of
consequences. Individuals will be less affected by consequences when they are
sleepy, or otherwise pre-occupied by other things.
The "law of exercise" stated that a connection between a stimulus and a response
becomes stronger with practice (and weaker in the absence of repeated trials).
He believed that "Instruction should pursue specified, socially useful goals" and therefore studied "Adult
Learning". He believed that the ability to learn did not decline until age 35, and only then at a rate of 1 percent per
year, going against the thoughts of the time. Thorndike was one of the first pioneers of "active" learning, that
proposes letting children learn themselves, rather than receiving instruction from teachers.
He authored 50 books and more than 450 articles. He was deeply interested in measuring differences in
intellectual capacity and performance among school children. It seems that his thinking on human differences
was motivated by his eugenic beliefs. He was active in the eugenics movement from the 1910s throughout the
1930s. At various times in his career he belonged to the Eugenics Section of the American Breeders Association,
the Eugenics Society of the USA, the American Eugenics Society, and the Eugenics Research Association.
[Source/picture]

Clark Hull
Hull has a background as physicist and engineer and devised a complex, formal and
systematic theory of behavior.
He noted that the strength of a stimulus is important in whether a response is
displayed. For example, someone quickly whispering "boo" won't cause another
person to flinch, but yelling it is more likely to do so.
The importance of the strength of the reinforcer on the display of the response was
also described. For example, an adolescent who runs an errand for an adult and

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receives a penny in payment, may not agree to run another errand. However, payment of a dollar is more likely to
result in a future errand running response to the request.
Hull also described "secondary reinforcement" in which a previously neutral stimulus takes on reinforcing
qualities. For example, giving a dollar to a six month old child is less likely to produce a reaction to a request than
giving it to a six year old, or an unknown actor's autograph may not bring any money until success makes that
previously neutral stimuli (no response happens to it's presentation) become a desirable commodity.
[Source/Picture]

Ole Ivar Lovass

Lovass is considered as the "father" of applied behavior analysis, the procedures
that involve the systematic environmental modifications used to understand and
change the behaviors of humans, mostly through his work with children with
autism. These procedures are also known as "behavior modification", "behavioral
treatment", or "behavioral intervention".
His program of intensive one-to-one teaching with repeated trials (practice
sessions) was based on the work of Skinner and others. He attracted some
criticism early in his career when he advocated for the use of physical
punishment, (“aversive therapy") to teach children with autism. He later dropped
this orientation and developed positive and novel ways of teaching.
He is a Professor Emeritus of Psychology and teaches at the University of
California, Los Angeles.

Behavioral Syndromes after TBI in the DSM-IV-TR Classification [12]:

• Delirium due to traumatic brain injury

• Amnestic disorder due to traumatic brain injury
1. Transient and chronic types
• Dementia due to traumatic brain injury
• Personality change due to traumatic brain injury
1. Labile, disinhibited, aggressive, apathetic, paranoid, combined, other, and unspecified types
• Mood disorder due to traumatic brain injury
1. With depressive features
2. With major depressive-like episode
3. With manic features
4. With mixed features
• Anxiety disorder due to traumatic brain injury
1. With generalized anxiety
2. With panic attacks
3. With obsessive-compulsive symptoms
• Posttraumatic stress disorder
• Psychotic disorder due to traumatic brain injury
1. With delusions
2. With hallucinations

12 [Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 8th Edition] “Neuropsychiatric Aspects of Traumatic Brain Injury”, pg 390

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 The exceptional circumstances of behaviours occurring in context of ABI:

Severe brain damage effects physical health as a whole as well mental health. Recovery can be seen as
reorganisation on another, often less functional level. It can be referred to as a process of adaption in
1. physical functions, which is often difficult and prolonged, particularly the neurologic aspect;
2. cognitive functions, which often continues to occurr over years.

Typical physical health issues are:

• Neurologic: Vision impairment, cognitive impairment (forgetfulness, poor concentration), delirium, autonomic
dysregulation, drowsiness, fatigue, headache, epilepsy.
• GIT: dysregulation of bowl movement, incontinence
• Motor system: hemi-/paraparesis or -plegia, loss of fine motoric, hemibalism, truncal ataxia,
• Systematic: electrolyte dysregulation, such as magnesium depletion in acute phase; SIADH

Typical mental health issues are:

• Psychosis
Most frequently paranoid, but also other delusional believes, hallucinations. Commonest within 2 – 6
years post injury [13].
• Impulse control disorder, which may effect any area.
Most commonly aggression, sexuallity, verbal interaction, financial interaction. It may or may not be
associated with remorse.
• Depression
Depression is the most common mental health problem following ABI, resulting from physical damage or
the experience of ABI itself. It is associated with poorer ADL functioning at 6 months [ 14] and a 3-4 times
higher suicide rate [15]. 23% of ABI sufferers are understood to have suicidal ideas [16] and 17-18%
attempt suicide [17].
• Anxiety
Mild and infrequent anxiety is common after ABI and 20% suffer from an Acute Stress Disorder [18],
3.4% from Obsessive Compulsive Disorder [19] and up to 24% from Generalised Anxiety Disorder (here:
following stroke [20]).

Behaivors typically addressed

• Verbal aggression
• Physical aggression
• Sexually inappropriate behavior
• Socially inappropriate behavior
• Wandering or absconding
• Adynamia

13 [Fujii 2001, Sachdev 2001]

14 [Jorge et al 1994]
15 [Teasdale 2001]
16 [Simpson 2002]
17 [Teasdale 2002 Simpson 2002]
18 [Bryant 1998]
19 [Ghika 2000]
20 [Bogousslavsky 2000]

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 Spectrum of strategies used

• Medication
• Talking Therapies
• Behavior Management

Medication

• Antidepressants
Preferably SSRI's
• Benzodiazepines
Diazepam, Temazepam, Oxazepam, Clonazepam, Alprazolam
• Antipsychotics
Olanzapine, Risperidone, Amisulpride, Aripiprazole
• Mood Stabilisers
Lithium, Valproate, Carbamazepine, Lamotrigene

Talking Therapies

• Modified CBT
• Grief and loss
• Supportive psychotherapy

Behaviour Management

• Structure,
weekly routine, attendant care program, meaningful activities, case manager
• Consistency,
staff/carer training, family education

Management of PTA: What not to do

Great effort needs to be made to avoid:

• Sedation
• Physical restraint
• Formal behaviour modification
• Formal assessment
• Home leave

Management of PTA: What can be tried

• Reduce stimulation
• Reduce noise
• Single room if possible
• Restricted environment

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• Consistent (familiar) staff
• Family, friends, photographs
• Limit the number of visitors
• Provide frequent rest times
• Reassure the family
• Slow communication
• Minimal instructions and explanations
• Use distraction

Most Importantly

• Improvement usually occurs spontaneously in is therefore dependent on time, usually years.

Understanding the Behavior

• All behaviors displays a need.

• All behaviors communicates something.
• All behaviors have to be seen in the various contexts, such as the current situation, mental state, physical
health, personal history and cultural background.

The ABC of the understanding of behavior can be surmised in the following initial questions, the clinician may
ask him/herself:
• What gives rise to the behaviour?
• What sustains it?
• Evolutionary analysis:
1. What were the preceedings (Antecedent)
2. What was the Behaviour
3. What is the Consequence

Monitoring Behaivors

• Why monitor?
1. Baseline
2. Analysis of behaviour
3. Track progress
4. Evaluate effectiveness of behaviour programs
5. Medication response
6. Can have a positive effect by itself

• What to monitor?
1. Nature
2. Range
3. Frequency
4. Intensity
5. Antecedents
6. Consequences

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• How do we monitor?
1. Observe (incidental or dedicated)
2. Count
3. Record on paper

• Record on paper because it is:

1. Individualized
2. Target specific behaviours
3. For particular purposes
4. can be simple
5. Defined, for a finite monitoring period

• For example: OBS (The Overt Behaviour Scale)

• Designed in Melbourne
• Covers all forms of challenging behaviour.
• Provides an indication of severity, frequency and impact.

Getting to Know Ourselfs

• What is our attitude?

• What are the implications?

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 Forming a Relationship: The Client as Apprentice

Give:
• Maximum support,
• gradually withdrawn,
• leading to maximum independence

How to start: Manage the Antecedents

By working from the outside in, make changes to:

• physical environment
• nature of events
• sequencing of events
• demands made
• staff involved
• nature of personal interactions

How to Continue: Set the client up for success

By providing structure and consistency. The more severe the injury, the more structure the person is likely to
require. Structure may be provided by:
• routine
• consistent management
• clear expectations

In the same context, consistency may be provided by making sure:

• The person will know what to expect
• This will increase cooperation
• Feeling secure reduces the risk of challenging behaviour
• Consistency reduces the risk of inadvertently reinforcing an undesirable behaviour

By applying the concepts of “working from outside in”, “setting routine”, the “Apprenticeship model” providing
structure and consistency, your are likely to channel the way for a different response.

How to Support the Process

• talk through and signal each step

• frequently offer reassurance
• offer an estimate of time remaining (minutes or counting)

Also remember:
• Whatever we pay attention to will persist or increase and any interaction constitutes attention and it does not
have to be positive to be reinforcing:
1. explanations
2. counselling
3. discussion
4. reprimands

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• What we ignore will go away. The can be done by:
1. not looking at the person
2. no eye contact
3. not talking to them
4. not talking about them in their hearing
5. not reacting to the behaviour
6. pretending they are not there

Strategies - Verbal Aggression

• Make every effort not to take insults / blaming personally

• Do not react by arguing or trying to reason
• Firmly divert attention, alter the activity, have the person move from the situation or leave yourself
• Identify triggers which make the person agitated and avoid them if practical
• Respond positively to appropriate behaviours
• Establish regular enjoyable activities
• Record strategies that work and don’t work

Strategies - Physical Aggression

• Identify agitation as early as possible – know the triggers

• Avoid the triggers and over-stimulationwhenever possible
• Try to defuse the situation before it escalates
• Acknowledge feelings, avoid cornering or confrontation
• Have the person leave the situation or leave yourself
• Establish regular enjoyable activities
• Report any incidents

Strategies - Sexually Inappropriate Behavior

• Clear and consistent rules and boundaries

• Consider appropriate sexual outlets
• Introduce other enjoyable activities
• Dress code for staff
• Select workers that will give the best chance of success with the person
• Consider how to approach the person

Take Home Message

• Behaviorsim as well as ABI/TBI amalgate to a fascinating and complex field.

• Behaviorsim has influenced different parts of the world in different ways and to different degrees.
• Both provide very usefull grounds for any other psychiatric field.
• It needs practice.

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