Applied Behavior Analysis as Treatment for Behavioral Issues Resulting from Traumatic Brain Injuries

Traumatic brain injury occurs as the result of an outside force impacting the head with enough force to cause direct or indirect damage to the brain, often resulting in serious medical and psychological issues for which there may be no medical cure. Applied behavior analysis offers functional techniques to modify post-injury behaviors to help improve the standard of living and social capabilities of TBI patients.

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Each year in the United States, more than 2 million people are hospitalized for traumatic brain injuries. According to the Centers for Disease Prevention, almost 140 people die every day in the United States from TBI, and survivors can expect to face long-term disabilities including:

  • Impaired memory or thinking
  • Movement and sensation difficulties
  • Extreme problems in emotional function

These issues affect not only patients, but their immediate friends and family. It may be difficult or impossible to reverse the physical damage sustained from a traumatic brain injury, and repairs at the neurological level to return normal function in the damaged parts of the brain are beyond the state of the art in neurosurgery today.

However, brain plasticity represents a thread of hope for TBI patients and their families. Neuroplasticity describes the quality of the brain that allows regions once used for a particular function to be “trained” to take on new functions. For individuals with brain damage, this represents an opportunity to relocate the functions once processed in the damaged area to undamaged parts of the brain.

With the unfortunate impetus of a dramatic increase in combat TBI injuries in Afghanistan and Iraq due to the extensive use of improvised explosive devices, the military has engaged in exhaustive studies of neural plasticity in recovering veterans. A comprehensive study conducted on rats comparing various treatment modalities found that significant motor function could be recovered with intensive behavioral rehabilitation.

Using Applied Behavior Analysis to Re-train the Brain After TBI

Neural plasticity represents an avenue of treatment for TBI involving the use of applied behavior analysis. ABA has been shown to be effective at treating a number of different issues experienced by TBI patients, including:

  • Aggression
  • Non-compliance
  • Lack of motivation
  • Anxiety
  • Depression

Behavioral analysis techniques are also used in rehabilitative therapies, helping TBI patients relearn basic tasks of self-care and daily living, and teaching vocational and social skills.

In TBI cases, ABAs have to work closely with other medical professionals in orchestrating treatments. Medical issues will be paramount during the early part of the patient’s recovery, and the behavior analyst may be primarily involved by passively observing and conducting a functional behavior analysis (FBA) to identify problems and potential solutions for injury-related behaviors.

It’s particularly necessary during the FBA of TBI patients to determine whether or not behavioral issues are due to a loss of basic skills, or due to environmental factors. TBI patients frequently exhibit idiosyncratic behaviors after their injury. This may be because they have lost certain faculties, which need to be retrained, or because their motivations (social conditioning and consequences) have been lost.

In these cases, the neurological linkages that typically tie together behaviors and consequences for those behaviors may be severed. Social cues that the patient would have picked up on easily before the injury may not be apparent, and additional training, or prompting, may be necessary to renew appropriate behaviors.

Later in the course of treatment, the ABA will formulate a behavior intervention plan (BIP) that seeks to apply behavior analysis techniques to alter environment or consequences in order to modify behaviors. When implementing the BIP, the analyst will have to consult with other healthcare providers such as:

  • Surgeons
  • Doctors
  • Nurses
  • Physical therapists

These professionals will have important information on the patient’s diagnosis and input on capabilities and therapeutic approaches that are compatible with medical necessities. The ABA will also usually need their cooperation in the implementation of the BIP, since they will have a considerable amount of hands-on contact with the patient. Consistency in the way that they reinforce behaviors in accordance with the BIP is critical to the overall success of the plan.

ABAs often have to start out with extreme basics when dealing with TBI patients who have had memory and cognition impacted by their injuries. Some of the simplest treatments bear remarkable resemblance to animal behavior training techniques, including:

  • Stimulus control – Creating associations between positive reinforcements and desirable behaviors.
  • Chaining – A series of stimulus responses used to help shape more complex behaviors.
  • Response Practice – A rote method of practicing responses to various regular stimuli, such as flashcard practice.

In one case, the use of stimulus equivalence was used to successfully train three TBI patients to regularly recall the names of their therapists on seeing their faces, a feat that had eluded them through the course of many prior rehab techniques.

The military is also experimenting with combining ABA with a hybrid therapy practice called cognitive behavioral therapy, or CBT. CBT involves combining practical aspects of applied behavior analysis in treating problematic behaviors with interactive cognitive therapy to address psychological aspects of the problems. The approach has been successful in treating a variety of mental health conditions which commonly overlap with traumatic brain injuries, including depression and post-traumatic stress disorder.

Environmental modifications are also used frequently to help TBI patients adjust to normal behaviors. Many TBI cases are accompanied with extreme physical injuries, including amputations. Physical modifications to restroom and dining facilities or patient workstations can be critical in making skill and behavior training achievable.

From Hospitals to Homes, ABAs Work in the Environment the Patient Inhabits

ABAs who work with TBI patients generally work in one of three different settings:

  • Acute care hospitals
  • Inpatient rehabilitation facilities and private care clinics
  • Educational settings, including public and private schools

During the earliest stages of treatment, patients will be seen in hospitals, where their medical issues are being addressed.

Later, ABAs will commonly work with TBI patients as they attempt to transition to more normal modes of living. This will often include a transitional period in a long-term care facility, where rehabilitation is strongly emphasized. ABAs may also continue working with patients who have been discharged and are adjusting to life at home again. They work with families, co-workers, and other caregivers to maintain the BIP.

Preparing for a Career Treating TBI as an Applied Behavior Therapist

A strong medical background is important for dealing with traumatic injuries, even as a behavioral analyst. Understanding the damage mechanisms and the various medical treatments that the patient will undergo can be vital in constructing appropriate behavioral therapy approaches. An undergraduate degree in biology or pre-medicine can be helpful in this respect.

Behavior analysts who work in injury rehabilitation will need to have an advanced degree in psychology or applied behavior analysis and almost always have to earn a Board Certified Behavior Analyst (BCBA®) certification from the Behavior Analyst Certification Board (BACB). This national certificate is a precursor for licensing in most of the states that have ABA license requirements. Even in states without a licensing statute, BCBA®s are usually listed as job requirements and are frequently demanded by insurers for the purpose of billing for ABA services.

Another helpful certification for TBI specialists is the Certified Brain Injury Specialist (CBIS) certificate offered by the Brain Injury Association of America.

Further Resources for Treating Traumatic Brain Injury with Applied Behavior Analysis

Brain Injury Association of America – A non-profit organization dedicated to advancing awareness, treatment, research, and education to improve the quality of life of patients and families impacted by traumatic brain injuries.

Centre for Neural Skills – Offers various continuing education resources focused on TBI.

Brainline – An overview of ABA techniques commonly applied in TBI cases.

Association for Behavior Analysis International Special Interest Groups – At least two of ABAI’s SIGs touch on TBI-related issues: the Rehabilitation and Independence SIG and the Behavior Analysis in Military and Veteran’s Issues SIG. The Neuroscience SIG also may have applicable considerations.

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