Association for Behavior Analysis International

Maladaptive behaviors are a common difficulty following traumatic and acquired brain injury. The related neurological deficits contribute to the complex nature and significant challenge experienced by those providing treatment to this population. The range of injury severity from concussions to severe trauma combined with the co-occurring medical and disease processes, make each case unique and complicated. The first study addresses the brain's anatomy and function while outlining the anticipated deficit areas related to damage experienced in the primary brain locations. This study further describes case examples to illustrate the challenges faced in behavior programming determined by the injury itself. The second study outlines the common problem of social skill deficits presented in this population. The study outlines the concept of using a direct instruction format to improve these valuable skills. Examples of the cirriculum are presented along with preliminary descriptions of treatment results and future research. The third study outlines the challenge of countercontrol in problem behavior post brain injury. Several case studies are presented to highlight the effects of social roles in therapy, using positive reinforcement to lessen the effects of conditioned aversive stimulation, providing choices, modeling, managing more dangerous countercontrol behaviors safely while minimizing extraneous attention, and programming for countercontrol when designing token economies. These studies all focus on treatment techniques that provide hope for positive change following traumatic and acquired brain injury. Future research, treatment protocols and staff training will be reviewed.

According to the Centers for Disease Control and Prevention (CDC, 2009), 10 million Americans are affected by stroke and traumatic brain injury (TBI), making brain injury the second most prevalent injury and disability in the U.S. The functional impacts of a brain injury can range from mild to severe and can affect individuals in the following areas: cognition, speech, physical, behavioral, and emotional. Maladaptive behaviors following a brain injury may include physical aggression, emotional lability, anger outbursts, impulsivity, social inappropriateness, and confabulations (CDC, 2009). Unfortunately, Individuals having a TBI who engage in problematic or unmanageable behaviors have a more difficult time accessing services and are most likely to become homeless, institutionalized, or imprisoned (Government Accountability Office, 1998). The current proposal introduces brain injury, a brief anatomy of the brain, magnetic resonance imaging and behavior correlates for three specific patients, and the use of applied behavior analysis techniques as treatment to individuals having a TBI.

The Center for Disease Control and Prevention reports that traumatic and acquired brain injury affects up to an estimated 10 million people each year. The severity of deficits suffered following such an injury can range from mild to severe, with thousands affected not even knowing that they have suffered a major injury. One detrimental effect of a brain injury can be the loss of identifying and understanding appropriate social cues when interacting with others. Brain injury survivors display deficits in social skills ranging from poor maintenance of appropriate topics of conversations to mishandling complex interpersonal relationships. This investigation aims at introducing direct instruction to traumatic and acquired brain injury survivors with identified social skill deficits post injury to determine if direct instruction has an impact on the reacquisition of social skills.

Brain injury rehabilitation can be an intense and challenging process with demanding social contingencies that can occasion behaviors to escape and avoid conditioned aversive social stimulation. In the rehabilitative context, countercontrol involves behaviors that function to punish or not reinforce the "controller's" (often in this case the treatment providers) behavior such that escape or avoidance may occur (Delprato, 2002). Three case studies are presented to illustrate countercontrol behaviors in the rehabilitation context and programming for effective approach strategies. The case studies respectively highlight the importance of considering the effects of social roles in therapy and how to mediate them, building strong rapport and using positive reinforcement to lessen the effects of conditioned aversive stimulation, providing choices as appropriate opportunities for control, modeling and using a collaborative approach to task completion, managing more dangerous countercontrol behaviors safely while minimizing extraneous attention for them (in so far as is possible), and programming for countercontrol when designing token economies. In summation, an ecological approach may have utility to account for the sociocultural context of rehabilitation in which countercontrol behaviors occur and to program accordingly (Ludwig & Geller, 1999).