Abstract
Background: Behavioral strategies often are used with people with acquired brain injury. Most involve the application of contingent reinforcement and punishment for selected behaviors or teaching important skills to overcome the challenging behaviors. However, consequential intervention and other strategies that depend on new learning may be precluded when working with individuals with significant short-term memory impairment.
Main Outcome Measures: The present case study reports the results of non-consequential strategies based on a positive, multi-element model to address physical aggression and other related problems for such an individual.
Results: Support did not involve the use of aversive consequences for challenging behaviors nor the use of physical management/restraint. The identified problems were effectively and safely addressed and community living in close proximity to his family was maintained.
Conclusions: The implications of this approach for the support of people who face similar challenges are discussed, including the ability to address serious problems such as physical aggression without resorting to aversive procedures.
BEHAVIORAL PROBLEMS such as physical and verbal aggression, noncompliance, self-injury, and sexually disinhibited behavior represent clear barriers to community reintegration and often do not remit spontaneously with time. 1,2 Brooks and colleagues 3 conducted a 5-year study of the outcome of severe head injury on close relatives of the individual. At 5 years 54% of the respondents reported threats and gestures of violence and 20% reported that the patient had been physically violent with a relative.
Most behavioral strategies designed to manage the behavior of people with brain injury have involved the application of reinforcement and punishment contingencies with the goal of gradually changing behavior over time. This has included the application of token economies, 4,5 time out from positive reinforcement, 6,7 response cost, 8,9 contingent restraint, 6 reinforcement of alternative behaviors, 5 behavioral momentum, 10 guided compliance, communication training and extinction, 10 and differential reinforcement of low rate behavior. 7 These strategies generally depend on the person's ability to learn from the consequences of his or her actions. However, some people with severe brain injury may have difficulty learning from the consequences of his or her behavior. Wood and Eames 7 assert that traditional consequences that involve reinforcement and/or punishment may not be effective with some people with acquired brain injury because of neurological damage. The following case study reports on Albert, a young man with just such a history.