a neurobehavioural rehabilitation approach to the ......27 nbr in practice • promotes and...
TRANSCRIPT
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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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Aggression after ABI
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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Aggression after ABI
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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Aggression after ABI
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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Aggression after ABI
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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Aggression in NbR Services
Aggressive behaviour exhibited by 108
participants in NbR over a 14 day period
5548 episodes
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Aggression in NbR Services
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’?
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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Aggression Reduction in NbR
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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Aggression Reduction in NbR
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 in NbR Services
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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Aggression in NbR Services
• 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
neuro- psychiatric
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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Assessment of ABI Aggression
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Assessment of ABI Aggression
• 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
25
70
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mild moderate severe very severe
80
14
6
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verbal prompt verbal guidance agitated/distressed
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100
talking to patient
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1 3 5 7 9 11 13 15 17 19
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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Differential Reinforcement Procedures
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 Procedures
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 Procedures
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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Lorazepam
Haloperidol
Procyclidine
Carbamazepine
1 2 3 4 5 6 7 24 25
initial admission
15 min fixed Interval DRI follow-up
frequency
severity intrusiveness
freq
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mea
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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 Procedures
Differential Reinforcement of Low Rates of Behaviour
(DRL)
Reduce a Behaviour
Reinforcement delivered when target behaviour is performed less often
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Differential Reinforcement Procedures
• 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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1 6 11 16 21 26 31 36 41 46 51 56 61
b’line 50> 40> 30> 20> 10> 5> 0
5 d
ay a
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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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Differential Reinforcement Procedures
• 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.