Applying Behavioral Principles in the Neurorehabilitation ... ... Applying Behavioral Principles in

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  • Applying Behavioral Principles in the Neurorehabilitation of People with Brain Injury

    Joseph N. Ricciardi, PsyD, ABPP, BCBA-D, CBIST Seven Hills NeuroCare Seven Hills Foundation

    BIAC Annual Professional Conference—March 17, 2017

  • Today’s topic

    Applied behavior analysis and neurorehabilitation? “I thought you guys were all about intellectual disability?”

    “ABA is a treatment for kids with autism, right?”

    There are far more applications of behavior analytic principles to support neurorehabilitation than many

    might realize

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  • Today’s topic

    What is ABA? A brief background  Origins

     Current practices and practitioners

    Some examples of applications  Within ABI population

     Problem behavior

     Acquisition of functional skills, life skills, and cognitive skills

    Behavioral learning principles  Basic principles of learning and behavior change

     Teaching techniques and strategies

    Writing and organizing a learning plan

    Behavioral skills training  Strategies for training and supervising implementing staff

  • Applied behavior analysis (ABA)  The application of the principles of learning and motivation from

    behavior analysis, and the procedures and technology derived from those principles, to the solution of problems of social significance.

    What is ABA? A brief background

    Behavior Analysis: Two primary areas of study  Experimental analysis of behavior

    o Basic research. Scientific research on behavior, learning, behavior change, etc. This is the basic science behind ABA.

    o Emerging ties to neuroscience (learning, memory, rewarded- behavior)

     Applied behavior analysis o This is applied research. Principles

    of learning are used to solve socially significant problems and experimentally validated. The result are techniques and procedures used as interventions.

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  • Practices  Applied. The application of the basic science of learning to solve

    problems.

    What is ABA? A brief background

     Behavioral. The focus is always on what can be observed and measured. “Behavior is what someone does”.

     Data-based. Data-based: careful observations, measurement, review, analysis.

     Technological. Uses techniques that can be described adequately so they can be used by others (the concept of a detailed “treatment plan”.

    Practitioners: Who is qualified to provide behavior analytic services?

     Current standard of practice: Board Certification (BCBA, BCBA-D)  LBA: Licensed Behavior Analyst (Massachusetts)  BCABA and RBT (registered behavior technician)

  • ABA is employed across a range of populations and for a variety of clinical problems  Populations referenced in ABA literature

    o Intellectual disability

    o Autism

    o Chronic and persistent mental illness

    o Brain injury

     ABI clinical problems referenced in behavior analytic literature o Reduction of challenging behavior

    o Functional improvement of motor skills (ADLs, IADLs)

    o Functional improvement of cognitive skills

    What is ABA? A brief background

  • An example: The work of Edward Taub  Behavior analyst  Was experimentally testing the

    “reflex” theory of behavior  Following surgical abolition of

    sensation from a forelimb, the animal would no longer use the limb

     Behavioral model: “learned non-use”

    ABA for ABI?

     Taub was able to show that with “operant conditioning” (B. F. Skinner), the animal could be trained to move the limb again

     Later experiments, he would restrain the unaffected limb for long periods, provoking improved movement and resumption of functional use in the affected (“dis-used”) limb

     Constraint induced movement therapy

  • Recent meta-analysis of ABA-based approaches applied in cases of brain injury (Heinicke & Carr, 2014)  112 studies meeting inclusion standards for experimental procedures

    and documentation of ABI

     Studies included children and adults

     Studies included both behavior reduction and skills acquisition using ABA

     Heinicke, M. and Carr, J. (2014). Applied behavior analysis in acquired brain injury rehabilitation: Meta-analysis of single-case design intervention research. Behavioral Interventions, 29, 77-105.

    ABA for ABI?

  • Recent meta-analysis of ABA-based approaches applied in cases of brain injury (Heinicke & Carr, 2014)

     ABA interventions classified as Well-Established or Probably Efficacious for acquiring/re-learning skills and adaptive behaviors (moderate to large effect-sizes): o Positive reinforcement o Modifying antecedents (adding visual cues, modifying schedules

    and routines, etc.) o Self-management

     And, Well-Established or Probably Efficacious for reducing challenging behaviors: o Differential reinforcement o Antecedent control o Self-management o Extinction

    ABA for ABI?

  • An older review evaluated 65 studies focused on behavioral intervention for problem behavior only (Ylvisaker et al, 2007)  65 studies, 172 participants  Contingency management (26), PBS+ABI (22), PBS (17)

     Ylvisaker, Turkstra, Coehlo, Yorkston, Kennedy, Sohlberg, & Avery (2007). Behavioural interventions for children and adults with behavioour disorders after TBI: A systematic review of the evidence. Brain Injury, 21, 769-805.

    ABA for ABI?

  • An older review evaluated 65 studies focused on behavioral intervention for problem behavior only (Ylvisaker et al, 2007)  65 studies, 172 participants  Contingency management (26), PBS+ABI (22), PBS (17)

     Ylvisaker, Turkstra, Coehlo, Yorkston, Kennedy, Sohlberg, & Avery (2007). Behavioural interventions for children and adults with behavioour disorders after TBI: A systematic review of the evidence. Brain Injury, 21, 769-805.

     Most studies employed a multi-component approach where 2 or more interventions were combined in a package

    o Modified structure and routine o Modifying task expectations to ensure success o Well understood daily routine (schedules, counsel, etc.) o Choice and control over activities o Personally meaningful activities (preferences) added to day o Positive behavioral momentum before difficult tasks o Errorless learning techniques o Positive feedback (reinforcement), support, encouraging interactions o Teaching communication alternatives to challenging behavior

    ABA for ABI? M

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  • An older review evaluated 65 studies focused on behavioral intervention for problem behavior only (Ylvisaker et al, 2007)

     Ylvisaker, Turkstra, Coehlo, Yorkston, Kennedy, Sohlberg, & Avery (2007). Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence. Brain Injury, 21, 769-805.

    They argue that PBS is well-suited for problem behavior in ABI:

    1. Ventral frontal lobe injury: reduces capacity to learn from consequences

    2. Dorsal frontal lobe injury: initiation impairment, limiting “contingency contracting”

    3. Frontal-corticolimbic injury: impaired contingency learning, impaired social judgment and perceptiveness; emotional regulation/self-control

    ABA for ABI?

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