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PBS Four-Step Beginner’s Guide © Positive Behaviour Support (PBS) following a Brain Injury 1 Identify the function of behaviour 3 Managing triggers 4 Responding to the behaviour 2 Preventative strategies

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PBS Four-Step Beginner’s Guide ©

Positive Behaviour Support (PBS) following a Brain Injury

A Four-Step Beginner’s Guide

2 Preventative strategies

4 Responding to the behaviour

3 Managing triggers

1 Identify the function of behaviour

“There is always something that works!”

-Feeney, 2010

2

Brain injury often results in cognitive and behavioural changes.

Behaviours of concern may include:

Physical & verbal aggression (e.g. hitting, verbal abuse) Sexually inappropriate behaviours (e.g. suggestive touching, flashing,

sexual propositions) Socially inappropriate behaviours (e.g. staring at others, using foul

language, urinating in public) Absconding (wandering off) Apathy (lack of interest or concern) Reduced initiation Reduced social skills Irritability Symptoms of mood disorders

Behaviours often become challenging when they are perceived to be of such intensity, frequency or duration that personal safety is at risk, or if the behaviour negatively influences relationships or community participation.These behaviours may have been present before the brain injury, or only appear afterwards. Coming to terms with and managing these can present unique difficulties for the individual with brain injury, their family and caregivers.

Why do behaviours of concern occur?

Behaviours of concern often occurs as a result of a combination of neurological, reactive and premorbid factors (from before the injury).

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Neurological factors

Behaviours of concern are often a direct result of the brain injury itself. Damage to the brain can result in a wide range of changes, including impulsive behaviour, reduced tolerance, distractibility and cognitive difficulties (e.g. problem solving, learning, memory, decision-making and reasoning). These will be different for each individual, and will depend on where and how the brain was damaged.

What changes might occur following brain injury?

Slowed information processing (delayed responses) Difficulty following a sequence of events (not knowing what happens

next) Mental fatigue Short attention span Poor concentration Easily distracted Difficulty learning new things or remembering new information Difficulty working out how to do things (problem solving) Unable to think of a new solution (flexible thinking) May repeatedly refer to the same topic or keep returning to that topic May start something without considering options or consequences May take things literally May not pick up on social cues (e.g. non-verbal cues – i.e. someone

hinting to finish the conversation) May be unaware of own limitations and have unrealistic expectations

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The person with brain injury may be unaware of their tactlessness or inappropriate behaviour. This is due to damage to the frontal lobe. They may not be able to monitor their behaviours and learn from their mistakes due to reduced insight and memory difficulties

They may be slow to respond to change, and more easily disturbed by change to routine.

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Reactive factors

Apart from the brain injury itself, there are other factors which may affect the person’s behaviour. These may include:

Feelings of loss and frustration Spending a lot of time attending appointments Less contact with friends Reduced income and the financial uncertainty of the future Difficulty returning to work or finding work Physical changes Reduced independence and the need to rely on others for day-to-day

activities Pain Fatigue Other health issue (e.g. seizures, mental health)

Premorbid factors

It is also important to consider the person’s cognitive, social and behavioural traits from before the brain injury (e.g. problem solving skills, personality and coping style, & cultural factors).

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Basic management strategies

Speak clearly, using short and simple sentences Repeat information if necessary Keep activities and instructions short and uncomplicated Prompt individuals to the next step in a task (or before moving to the

next activity) Limit distractions Identify achievable outcomes, ensuring there is a purpose Keep the environment organised Keep calm and in control, and avoid emotional undertones (e.g. say yes,

but mean no)

Small changes in the way we respond and interact with a person may significantly change their behaviours

Allow time Set achievable goals/ tasks Reduce distractions Communicate in a clear manner

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Managing behaviours of concern

It’s easy to become all consumed with the ‘problems’. First separate the person with brain injury from their behaviours of concern. Whilst a particular behaviour may be undesirable or offensive, it’s important not to make negative judgments about the whole person.

Remember to focus on the individual’s strengths, as well as their difficulties, and believe that there is capacity to replace the challenging behaviours with more adaptive ones.

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Identify the function (purpose) of the problem behaviour?

But how do you know what the function is…?

To identify the function of a behaviour, it is important to think about the triggers and the response to the behaviour when it occurs. This can be identified through careful observation (see following page).

A trigger is something that causes a reaction in the person (behaviour)The response refers to the reaction to the behaviour.

Automatic reinforcementAvoidanceEscape Access to itemsAttention

Behaviour

ResponseBehaviourTrigger

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Observing the behaviour of concern

The first step in analysing behaviour is observing the behaviour when it occurs in its natural environment. This may reveal patterns of when the behaviours are most likely to occur, in which environment, and in whose company.

But first it is important to make sure you know what specific behaviour you are observing. Make sure you record the behaviour in observable terms.

Not Helpful Helpful“Bill had an aggressive

outburst”

“John was sexually inappropriate”

“Bill punched his brother on the cheek with a closed fist”

“John touched the breast of a female support worker”

When recording behaviours we should avoid ambiguous terms, such as “aggressive”, “sexually inappropriate”, or “disinhibited”. This will ensure agreement as to the exact nature of the behaviour, leaving no room for interpretation.

It is important to take note of: The environment/ setting Time Who was present The trigger and response to the behaviour

Your observations may reveal some patterns in the behaviour of concern, including similar times/ settings when the behaviours occur, and perhaps consistent responses that may play a part in reinforcing the behaviour.

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Preventative Strategies

Preventative strategies include: Environmental changes Developing routines Ensuring choice/ control for the individual Ensuring meaningful activities Compensative strategies for cognitive difficulties (e.g. using reminders)

Preventative strategies are very important when designing interventions for people with brain injury, as individuals often have difficulty in understanding and processing information.

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Environmental changes

Environmental changes may be necessary due to cognitive and/ or physical changes resulting from the brain injury.

There may be a close link between behaviours of concern and environmental factors (e.g. frustration using particular door handles, or never knowing where the sugar bowl is!). These behaviour may be resolved by making sure the environment is organised and appropriate to the person’s physical abilities.

Routines

Routines are important for a person with brain injury. Following brain injury, a person may have difficulty starting activities, planning how to do them, and maintaining concentration. Routines can help to prompt the person with brain injury with what needs to be done and in what order.

How to set up a routine

When setting up a routine: Involve the person as much as possible Incorporate their preferred routine

(e.g. what time do they like to get out of bed? Do they like to have a shower in the morning or evening?)

Display the routine somewhere visual

STRUCTURE and ROUTINE are the keys to independent functioning and success following brain injury.

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Meaningful activities

How does this relate to behaviour management? Consider how you feel when you are doing something that you are enjoying or something that gives you a sense of purpose. Now compare that with how you feel when you do something out of obligation, or feel bored and uninspired by what you are doing or by your surroundings.

People who are engaged in meaningful activities are going to feel more positive, and when we are feeling positive, this is more likely to be reflected in our behaviour. Likewise, if we feel a sense of purpose or responsibility, we will feel more important and valued by others.

It is therefore important that meaningful activities are incorporated into the individual’s routine. If an individual feels good about their routine, they will be more likely to cooperate when they are required to do necessary but less desired activities (e.g. showering, brushing teeth, dishes, etc).

It might help to consider the following questions: What are the individual’s interests? What do they like/ dislike? What are their strengths? What are they good at? When do they seem most engaged?

But I don’t like the Footy!

C’mon, it’s time to go to the Footy…

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Managing triggers

A trigger is something that causes a reaction in the person (behaviour). When observing the problem behaviour, you might identify possible triggers. These might include:

Noisy/ busy environments Specific sensory stimuli (e.g. wind/ high-pitched sounds) Being over or under stimulated Particular people/ environments/ times/ activities Particular communication styles (e.g. authoritarian approach)

Once you have identified possible triggers, you may be able to avoid these situations, or help the individual develop coping strategies to manage these. For example, if you identify crowded situations to be a trigger for an individual, then it would be a good idea to avoid noisy/busy environments (e.g. going to a football match may not be appropriate).

Early warning signs

As a person becomes angry, a change occurs at a physical, emotional or cognitive level. If these changes are caught early enough (i.e. Before a person loses their temper) then they can be used as an ‘early warning system’.

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So, even if you can’t identify the trigger, the persons physical, emotional or cognitive changes might help you identify that the person is becoming irritable or angry.

The following changes may be used as guideposts:

Physical Emotional Cognitive-Muscle tension-Temperature change-Tremor/shaking-Sweating-Heart pounding-Clenched fists

-Irritated-Frustrated-Moody-Unsettled-Feeling upset

Changes to thoughts include:-Racing-Jumbled-Irrational-Jumping to conclusions

Responding to the behaviour

When a behaviour is escalating, make sure you keep calm and in control. Avoid mirroring behaviour (e.g. yelling response to someone being

verbally aggressive) Controlled breathing (take deep slow breaths) Control voice (speak with a calm tone)

It is also important to use non-confrontational body language. Keep hands open and in full view Avoid staring or standing with your hands on your hips Avoid making fast movements

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Think about the situation

Is there anything reinforcing the behaviour? (e.g. things in the environment or responses to the behaviour)

Is there anything frightening the person? Is there anything frustrating the person? Do they have unmet needs? Are they being over or under stimulated?

Decide on a response

This might include: Negotiation (only if the person isn’t too agitated) leaving no action surprise Distraction Humour

… OK, how about a Cuppa Break?

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There are a number of behaviour strategies that help increase/ maintain desired behaviours, and decrease behaviours of concern. These strategies focus on rewarding desired behaviours, whilst not providing ‘payoffs’ for problem behaviour.

The concept is simple: each time the person engages in the desired behaviour, you reward them, which increases the likelihood of this behaviour occurring again in the future. At the same time, you withhold ‘payoffs’ for problem behaviour. For example, if you have identified that an individual is verbally aggressive to gain attention from staff, then withdrawing this attention would be appropriate.

If you choose to withhold payoffs for a problem behaviour, please consider the following:

- All caregivers must consistently apply this approach for it to be effective- Positive reinforcement should be applied for desired behaviours at the

same time (rewarding desired behaviours)- The behaviour may increase initially, as individuals may try harder to get

the response they were looking for

Please note that contingency strategies (which involve manipulating the response to behaviour to encourage or discourage behaviour) should only be used with individuals who do not have difficulties with information processing and memory

It is also important to observe how often the target behaviour occurs before and after implementing strategies. This will help you identify whether your strategies are having an impact (i.e. is the behaviour occurring less?), or if you might need to change your approach.

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Perhaps the most effective reinforcers are verbal praise and attention. Think of how much we do for just a smile or some other form of acknowledgment from someone who is important to us.

Example: Ted’s support workers cooked him dinner every evening. They wanted him to be more helpful with cleaning up after the meal. They made a point of praising him every time he took his plate to the sink (after prompting). As a result, Ted started taking all of the dirty dishes to the kitchen. He is now responsible for cleaning the table after mealtimes and doing the dishes.

Example: George made inappropriate sexual comment around female staff. The more the staff tried to teach George that these comments were not welcomed, the more he said them. The female staff then agreed to ignore all the inappropriate sexual comments, but to readily engage him in conversation when he discussed other topics. At first George’s behaviour became more vulgar, however, after a brief period of time he stopped all sexual comments towards females and talked about more socially acceptable topics.

PLEASE NOTE: Behaviour Programs that address high-risk behaviours should only be implemented by specially trained professionals

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Crisis Management

If a behaviour is escalating quickly, it is important to:

Keep calm and in control Maintain a safe distance Use non-confrontational body language Think about the situation Decide on a response

It is important to acknowledge the concerns/ emotions of the person whether you agree with them or not. This validates his or her experience, helping them to feel ‘understood’. For example, you might say “I can understand that (situation) is making you feel upset…”

If danger is present, clear the space if possible and remove others from the scene. Also make sure you can always see the person – it is important to never turn your back on a person behaving aggressively.

Restraint, medication (if prescribed and available) and self-defense should only be used as a last resort.

If the situation seems uncontrollable, keep calm, leave as quickly as possible and go to a safe place.

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After an incident, it is important to debrief. Make time to speak with colleagues or your supervisor regarding the incident – can you identify why the behaviour occurred? How did you respond? Can you think of how the situation might be avoided in the future?

You may need to release tension after a crisis. You might like to try the following:

Relaxation Physical activity (physical release) Talking/ laughter/ crying (emotional release)

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Take Home Messages

Following brain injury, a person may experience changes in information processing, memory, cognition (thinking), personality/ behaviour, and/or physical ability

There are specific strategies that can be used to deal with these changes Careful observation may reveal triggers and responses that might be

reinforcing the behaviour. This will help you identify the function (purpose) of the behaviour (e.g. attention, avoidance) which is important in choosing appropriate management strategies

It is important to recognise that problem behaviour can be a secondary feeling (e.g. resulting from pain, fear, frustration or humiliation), and if so, dealing with the initial feelings may eliminate the problem behaviour

Preventative strategies (e.g. environmental changes, routines, meaningful activities) play an important role in behaviour management for people with brain injury, as individuals often have challenges in understanding and processing information

Rewarding (i.e. praising) desired behaviour will increase the likelihood of this behaviour occurring again in the future

If confronted with a crisis situation, keep calm and in control

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Information in this booklet has been informed by the following resources:

Dark, F. Understanding Challenging Behaviour following an Acquired Brain Injury. BRAIN INJURY Association (now Synapse). Murphy Schmidt Solicitors

Responding to challenging Behaviour Following an Acquired Brain Injury. BRAIN INJURY Association (now Synapse). Murphy Schmidt Solicitors

Jacobs, H. E. (1995). Behaviour Analysis Guidelines and Brain injury Rehabilitation. Aspen Publications, Inc.: Maryland

Martin, C. (2011). Working with people with traumatic brain injury: staff self-study Module 5: Understanding and managing behaviour changes following a TBI. Retrieved from http://www.tbistafftraining.info/SelfStudy/Module_5/5.0htmBrain Injury Rehabilitation Unit: Liverpool Hospital, Sydney

Ponsford, J., Sloan, S., & Snow, P. (2013). Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living. Taylor & Francis LTS: United Kingdom

Feeney, T. (2010). There’s always something that works: Principles and practices of positive support for individuals with traumatic brain injury and problem behaviours. Seminars in Speech and Language, 31(3), 145-161

Ylvisaker, M. & Feeney, T. J. (1998). Collaborative Brain Injury Intervention: Positive Everyday Routines. Thomson Learning: Canada

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STAFF TRAINING AVAILABLE

PBS Four-Step Beginner’s Guide © Flinders University 2016Written & designed by Alinka FisherIllustrated by David Heinrich

No part of this booklet may be reproduced or transmitted in any form without the prior written permission from the author.

Disability and Community InclusionSchool of Health Sciences P: (08) 82013745E: [email protected]

Disability and Community Inclusion UnitSchool of Health Sciences, Sturt CampusFlinders UniversityGPO Box 2100Adelaide SA 5001 Australiaflinders.edu.au/sohs