The effectiveness of DRL in the management and treatment of severe behaviour disorders following brain injury

Examining the Evidence From Single-Case Experimental Designs to Treat Challenging Behaviors Following Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate evidence on the effectiveness of behavioral interventions using single-case experimental design (SCED) methodology and to identify behavioral interventions with sufficient evidence for possible inclusion in the development of guidelines for the management of challenging behaviors in adults following moderate to severe traumatic brain injury (TBI).

METHODS

As a subinvestigation of a larger systematic review process designed to identify evidence for guidelines development, the current review focused on studies using SCED methodology applied to persons with challenging behaviors following moderate to severe TBI. Articles were identified from a search of the published literature through January 2021, identifying studies in CINAHL, Cochrane Database of Systematic Reviews, EMBASE, MEDLINE/Ovid, and PsycINFO. Articles meeting inclusion criteria were assessed for design rigor to allow for effect size determination. The identified cases were then critically appraised using the RoBiNT (Risk-of-Bias in N-of-1 Trails) Scale to determine strength of evidence for causal inference.

RESULTS

Thirty-four studies met inclusion criteria, with a total of 44 cases evaluated for effect of the treatment intervention on defined target behaviors. Seventeen cases had effect sizes rated as large, 22 cases as medium, 3 cases as small, and 3 as no effect. An observed trend was for large and medium effect sizes to be associated with lower RoBiNT Scale internal validity scores. Randomization, blinded provider and assessor, and assessment of treatment adherence were the internal validity items unlikely to meet criteria.

CONCLUSIONS

SCED methodology was found to produce large and medium effect sizes for behavioral interventions targeting challenging behaviors following moderate to severe TBI. However, the strength of the evidence is limited because of weaknesses in study designs. Most of the studies failed to meet established internal validity criteria designed to reduce risk of bias in SCED studies as such rigor is difficult to establish or often not practical in clinical settings. Suggestions and recommendations are outlined for improving the quality of published cases using SCED methodology, which, in turn, will improve credibility of evidence and better inform the development of treatment guidelines for behavior regulation.

Brain injury, behaviour support, and family involvement: putting the pieces together and looking forward

Purpose: (1) to provide insight into the family's experience and support needs following acquired brain injury (ABI) specific to behavioural changes; (2) to provide an overview of empirically-based behaviour support approaches for individuals with ABI; and (3), to examine family involvement in implementing behavioural interventions.Methods: Review of the literature.Results: Family members experience significant distress resulting from neurobehavioural changes in relatives with ABI, and report unmet informational and practical support needs regarding this issue. The importance of utilising family expertise within the rehabilitation process is widely acknowledged, with the increasing involvement of family members being promoted. There is growing evidence supporting the use of positive behaviour support approaches for individuals with ABI in community settings, and evidence supporting the involvement of family within behavioural interventions.Conclusions: This review suggests the need to develop alternative support models that shift the focus towards building competence in everyday support people rather than dependency on the service system. A bottom-up approach is recommended, with the aim of addressing unmet support needs and increasing the competence of family members in supporting behaviour change in individuals with ABI. Recommendations are provided in informing an optimal community-based neurobehavioural support model. Implications for RehabilitationPositive behaviour support is recommended in supporting behavioural changes following brain injury, with family expertise utilised in this process.Evidence suggests that family members can be effectively trained in developing and implementing behaviour support strategies.Family involvement in behavioural interventions may address unmet support needs and increasing the competence of family members in supporting behavioural changes following brain injury.

The role of signals in two variations of differential-reinforcement-of-low-rate procedures

Differential-reinforcement-of-low-rate (DRL) schedules are used to decrease the overall rate of, but not eliminate, a target response. Two variations of DRL, spaced-responding and full-session, exist. Preliminary comparative analyses suggest that the two schedules function differently when unsignaled. We compared response rates under these two DRL variations with and without signals. In Experiment 1, five preschool students played a game in which points were earned under DRL schedules. In some sessions, a stimulus signaled when responses would be reinforced (S+) or not reinforced (S-). In others, only an S- was present. Signals (S+/S-) facilitated and maintained responding in both types of DRL schedules. In Experiment 2, we modified the signals with five different preschoolers. Instead of an S- only, we did not present any signals. Elimination and high variability of the target response were observed with the S- only and absence of S+/S-, respectively. Signaled DRL schedules are recommended for application.

Differential Reinforcement of Low Rate Schedules Reduce Severe Problem Behavior

Differential-reinforcement-of-low-rate (DRL) schedules are reinforcement contingencies designed to reduce response rates. A common variation of the DRL arrangement is known as full-session DRL ( f-DRL), in which a reinforcer is presented at the end of an interval if the response rate during that interval is below a predetermined criterion. Prior human operant research involving arbitrary mouse clicks has shown that the f-DRL is likely to reduce target responding to near zero rates. Similarly, applied research has shown that the f-DRL is likely to reduce minimally disruptive classroom behavior. There are, however, relatively few successful applications of the f-DRL to severe forms of problem behavior (e.g., self-injurious behavior). Thus, the purpose of this study was to examine the effects of f-DRL on the severe problem behavior of individuals with intellectual and developmental disabilities. For four participants, the f-DRL reduced severe problem behavior by clinically significant levels. Furthermore, results of a contingency strength analysis showed a strong negative contingency strength between target responding and reinforcer delivery for all participants.

Further developments in summarising and meta-analysing single-case data: An illustration with neurobehavioural interventions in acquired brain injury

Data analysis for single-case designs is an issue that has prompted many researchers to propose a variety of alternatives, including use of randomisation tests, regression-based procedures, and standardised mean difference. Another option consists in computing unstandardised or raw differences between conditions: the changes in slope and in level, or the difference between the projected baseline (including trend) and the actual treatment phase measurements. Apart from the strengths of these procedures (potentially easier interpretation clinically, separate estimations and an overall quantification of effects, reasonable performance), they require further development, such as (a) creating extensions for dealing with methodologically strong designs such as multiple baseline, (b) achieving comparability across studies and making possible meta-analytical integrations, and (c) implementing software for the extensions. The proposals are illustrated herein in the context of a meta-analysis of 28 studies on (neuro)behavioural interventions in adults who have challenging behaviours after acquired brain injury.

Rehabilitation Approaches to the Management of Aggressive Behaviour Disorders after Acquired Brain Injury

Symptoms of neurobehavioural disability acquired through brain injury, especially aggression, are associated with severe social handicap. Differences in terminology have resulted in varying estimates, but aggressive behaviour disorder appears to be characteristic of survivors at some point in their recovery journey. This paper provides a brief review regarding the prevalence, development and causes of aggression associated with acquired brain injury (ABI), and what can be done to help manage them. The advantages of using standardised measures conceptualised for ABI in the assessment and formulation of aggressive behaviour disorders are especially highlighted. A range of treatment methods and the evidence base relating to these are described. The contribution of pharmacological therapies, cognitive behavioural therapy and behavioural interventions are explored. It is argued that the strongest evidence base is associated with behaviour therapy, especially when carried out in the context of neurobehavioural rehabilitation, and two case studies are described to illustrate the clinical advantages of interventions derived from operant theory. Comparative lack of ABI experts trained in the management of post-acute behaviour disorders remains a limiting factor.

Using differential reinforcement of low rates to reduce children's requests for teacher attention

We evaluated the effectiveness of full-session differential reinforcement of low rates of behavior (DRL) on 3 primary school children's rates of requesting attention from their teacher. Using baseline rates of responding and teacher recommendations, we set a DRL schedule that was substantially lower than baseline yet still allowed the children access to teacher assistance. The DRL schedule was effective in reducing children's requests for assistance and approval, and the teacher found the intervention highly useful and acceptable. The possible mechanisms that account for behavior change using full-session DRL schedules are discussed.

Behavioural interventions for children and adults with behaviour disorders after TBI: A systematic review of the evidence

OBJECTIVE

To systematically review the evidence for the effectiveness of behavioural interventions for children and adults with behaviour disorders after TBI.

DESIGN

Using a variety of search procedures, 65 studies were identified. This literature was reviewed using a set of questions about participants, interventions, outcomes and research methods.

PARTICIPANTS

The 65 studies included 172 experimental participants, including children and adults.

INTERVENTIONS

A number of specific intervention procedures were used, falling into three general categories: traditional contingency management, positive behaviour interventions and supports and combined.

RESULTS

All of the studies reported improvements in behavioural functioning.

CONCLUSIONS

Behavioural intervention, not otherwise specified, can be considered a treatment guideline for children and adults with behaviour disorders after TBI. Both traditional contingency management procedures and positive behaviour support procedures can be said to be evidence-based treatment options. However, a variety of methodological concerns block stronger conclusions.

Prevalence, characteristics and causes of aggressive behaviour observed within a neurobehavioural rehabilitation service: Predictors and implications for management

PRIMARY OBJECTIVE

To describe the characteristics and determinants of aggressive behaviour observed within a neurobehavioural unit.

RESEARCH DESIGN

Statistical analysis of a database of routinely administered clinical measures, including the Overt Aggression Scale-Modified for Neurorehabilitation.

METHODS AND PROCEDURES

Records of aggressive behaviour shown by 108 patients over 14 days were studied. Patient characteristics were also captured using 23 items from the Rehabilitation Institute of Chicago-Functional Assessment Scale. Four factors were identified: 'communication', 'cognition/function', 'neurobehavioural disability' and 'mood & self-esteem'. Relationships between patient characteristics, external factors and their interactions with aggression were examined.

MAIN OUTCOMES AND RESULTS

Many (5548) episodes of aggression were recorded. Whilst most comprised verbal aggression, 729 physical assaults were made on others. Aggressive behaviour typically followed staff prompting or no obvious antecedent. Medical intervention was rare, most aggression was managed by staff not reinforcing this behaviour. Over 80% of physical assaults were made by people rated as having severe symptoms of neurobehavioural disability and poor communication.

CONCLUSIONS

Neurobehavioural units require sufficient staff resources to engage patients in purposeful activities as these were associated with the least severe aggression. Despite increased OAS-MNR usage, a standardized methodology for investigating aggression is required to ensure compatibility between datasets.

Measuring the relationship between overt aggression and expectations: a methodology for determining clinical outcomes

The presence of aggressive behaviour following traumatic brain injury imposes special challenges within rehabilitation centres. Survivors of traumatic brain injury constitute a heterogeneous population amongst whom problems with increased irritability and aggression are characteristic. There is a clear need to determine what treatment approaches might be helpful in reducing aggressive behaviour. Whilst single-case experimental methodologies including reversal and multiple baseline designs seem ideal for this purpose, the compelling need to minimize risk can compromise their deployment, especially when aggression takes the form of physical assaults on others. When this is the case, there are difficulties in assessing whether a change in aggressive behaviour represents a successful response to treatment or is simply a function of reduced demand in the environment. The contributions made to understanding the relationship between aggression and expectations made on patients participating within rehabilitation will be explored here. A possible means of quantifying demands using the Neurobehavioural Expectations Scale will be described. Three case studies are presented that suggest that a methodology that employs concurrent use of this tool with the Overt Aggression Scale -- Modified for Neurorehabilitation, can enable objective evaluation to be made of the effects of rehabilitation on behaviour, without increasing risk.

[Non-pharmacological treatment of neurobehavioural disorders following severe traumatic brain injury. A commented literature review]

OBJECTIVES

Neurobehavioural disorders are a major public health problem and a daily challenge for neurological rehabilitation. This review presents the state of art in the field of traumatic brain injury regarding non-pharmacological treatments of neurobehavioral disorders.

METHODOLOGY

Medline data base and main reference books going back for 15 years were searched.

RESULTS

Prevention is based on information and counselling for a better coherence in the care and a better understanding of behaviour problems. Prevention of complications is based on adaptation of units and management (one-on-one care for example). Non-pharmacological treatment can be classified according to 3 approaches: (1) Behavioural approaches: with well-established procedures for each patient; (2) Holistic approaches: addressing both lesional and psychopathological as well as environmental features; (3) Psychotherapeutic approaches: either integrated to holistic programs, or adapted from classical psychotherapy, or systemic therapy.

CONCLUSION

Practices trend to a convergence through a comprehensive approach: behaviour analysis and management of its neuropsychological, psychopathological and environmental components. Everybody will be able to pick out elements adaptable for his own practice.

Treatment of maladaptive behavior in acquired brain injury: remedial approaches in postacute settings

This article describes remedial behavior therapy approaches for the treatment of maladaptive behavioral sequelae to an acquired brain injury (ABI). Remedial approaches are sophisticated and nonintrusive treatment strategies that involve teaching the individual skills or capacities to manage difficult life circumstances. Functional equivalence is one major category of remedial intervention and involves the determination of the behavioral function of the problem behavior and the teaching of an adaptive alternative response or skill cluster that provides the individual with efficient access to that function. Errorless remediation is a second category and entails teaching the individual to tolerate situations associated with problem behavior through hierarchical exposure to increasingly difficult conditions and reinforcement for successful management of those conditions.

A conceptual model for treatment of externalizing behaviour in acquired brain injury

This paper describes a conceptual model for treatment of the externalizing behavioural sequelae to an acquired brain injury and discusses relevant research. Use of the model by practitioners should lead to sophisticated and minimally intrusive intervention. In the model, there are two different categories of approaches. The first category is remedial approaches. These interventions are typically used in the post-acute environment for teaching adaptive skills to replace aberrant behaviour patterns. Skills provided with such training allow the individual to self-manage difficult everyday situations effectively, without external control by others. The second category is moderating approaches, which can be used in the acute phase of ABI recovery for management of severe behavioural episodes that may be associated with conditions present at this time, such as agitation and confusion. Moderating approaches can also be used as a prelude to remedial approaches in the post-acute environment when problem behaviours occur at a high frequency or intensity and render the use of remedial approaches difficult.

Reduction of severe aggressive behaviour in acquired brain injury: case studies illustrating clinical use of the OAS-MNR in the management of challenging behaviours

Challenging behaviour, especially when this takes the form of aggression, may impede or prevent progress in neurorehabilitation. Despite its prevalence, the literature on management of aggression after brain injury is not extensive. It has been suggested that the 'Overt Aggression Scale-Modified for Neurorehabilitation' (OAS-MNR) could be used to help standardize future studies of aggressive behaviour. It was also suggested that this scale has sufficient properties to be useful in clinical work. In this paper, three case studies are described which attempt to illustrate the potential value of the OAS-MNR in neurorehabilitation. The use of the scale also provides evidence relating to the continued efficacy of the neurobehavioural model. In the first study, two cases are described in which reduction in aggression occurred through participation in individualized, needs-led holistic treatment programmes, which incorporated multiple interventions. These were based on neurobehavioural principles. In the second study, a further single case was presented which illustrated how the scale may be used to generate hypotheses regarding aggressive behaviour and to drive treatment. Causation and maintenance of aggression are discussed, especially with regard to cognitive impairment. Finally, practical points relating to the use of the OAS-MNR in clinical practice are reviewed.