How Applied Behavior Analysis is used to Support Rehabilitation and Independent Living

Applied behavior analysis therapies are used to treat a variety of disabilities stemming from neurological injuries. Applied behavior analysts apply basic behavioral practices that improve language and social interactions and support rehabilitation and independent living among children and adults with brain injuries.

Brain injuries can be caused by a number of factors, and are a result of either an impact (traumatic brain injury) or an acquired disease or medical condition (acquired brain injury):

Traumatic Brain Injury

A traumatic brain injury (TBI) occurs when a blow to the head is severe enough to cause the brain to move inside the skull and sustain damage as a result. It may also occur if the impact causes the skull to fracture.

Though best known as a combat related injury among veterans involved in or very near to explosions, events like motor vehicle accidents, physical violence, and sports injuries can cause the nerve fibers of the brain to pull apart resulting in a traumatic brain injury.

Even some injuries without any outward sign of trauma (called closed head injuries) can result in a TBI because the brain swells and becomes compressed within the skull. Injuries of this sort are often even more serious than other types of injuries, as they are more likely not to receive proper medical treatment.

Every 21 seconds, a person in the United States sustains a traumatic brain injury. This equates to about 1.5 million people every year.

The impact is often long-lasting and devastating. Of the one and a half million people suffering from traumatic brain injuries (TBI):

  • 50,000 will die
  • 235,000 will be hospitalized
  • 80,000 will suffer long-term disabilities

The major causes of TBI are:

  • Falls – 28 percent
  • Motor vehicle accidents – 20 percent
  • Struck: 19 percent
  • Assaults: 11 percent

Acquired Brain Injury

Not all brain injuries are caused by an impact to the head. Acquired brain injuries result from a result of a lack of oxygen to the brain, which obstructs neural activity and damages the brain.

Acquired brain injuries may result from:

  • Airway obstruction
  • Aneurysm
  • Infectious disease
  • Heart attack
  • Stroke
  • Seizure
  • Strangulation
  • Encephalopathy
  • Brain tumor
  • Near drowning
  • Carbon monoxide poisoning
  • Illegal drug use and alcohol abuse

The Devastating Consequences of Brain Injury

According to the Centers for Disease Control and Prevention (CDC), about 5.3 million Americans currently have a long-term or lifelong need for help with their activities of daily living (ADL) as a result of brain injuries.

Some of the functional changes experienced by individuals with a brain injury affect language, thinking, emotions, and sensation. A brain injury may also increase the individual’s risk of developing Alzheimer’s disease, Parkinson’s disease, and other brain disorders.

There are many things that factor in to the degree to which a brain injury will affect a person’s ability to function, including the type of injury, the location of the injury, how quickly the injury was treated, the type of treatment received, and certainly the extent of the damage.

Some of the consequences of brain injury include changes in:

  • Physical
    • Muscle movement and coordination
    • Weakness
    • Fatigue
    • Lack of balance
    • Sleep problems
    • Loss of hearing, vision, taste, touch, smell, and speech
    • Seizures
    • Lack of sexual function
  • Thinking: Decreased
    • Memory
    • Judgment
    • Communication
    • Attention
    • Perception
    • Reading, writing, communication skills
    • Safety awareness
    • Thought processing
    • Problem-solving skills
  • Social
    • Reduced self-esteem
    • Mood swings
    • Lack of social skills
    • Lack of motivation
    • Depression, anxiety
    • Frustration, stress
    • Lack of anger management
    • Lack of coping skills
    • Irritability, agitation
    • Inappropriate behavior (lack of self-awareness, excessive crying or laughing)

Individuals with brain injuries may have difficulty entering or re-entering the workforce, handling social interactions and personal relationships, and have limited employment opportunities.

They are also at a higher risk for alcohol and drug abuse and often have an inability to handle basic household and personal tasks.

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How Applied Behavior Analysis is used to Support Rehabilitation and Independent Living Among Those with Brain Injuries

The applied behavior analyst’s job is not to treat individuals with brain injuries according to their symptoms, but instead their behaviors and how those behaviors are affected by environmental factors.

Applied behavior analysts carefully study the antecedents (what happens before the behavior), the behavior (the individual’s responses or skills), and the consequences (what happens after the behavior) of individuals with brain injuries. For example:

  • Antecedent: The individual tries to escape or avoid unpleasant situations or stimuli or may respond negatively to certain sounds, lights, smells, and tastes.

An individual has difficulty handling crowded rooms accompanied by a lot of noise.

  • Behavior: The brain injury reduces the individual’s ability to perform previously learned skills and learn new skills. Poor insight and judgment are common.

As a result of the environment, the individual experiences an emotional outburst.

  • Consequence: Along with changes in brain activity, the individual with a brain injury may appear more unstable, easily agitated, and more predictable. Their ability to maintain learned behavior-reinforcing relationships may be hindered.

The individual avoids public places and social situations, thereby putting relationships, employment and socialization at risk.

Understanding antecedents is of particular importance to applied behavior analysts when treating individuals with brain injuries because traditional behavior modification using reinforcement and consequences may be unsuccessful. ABA treatment may include making changes to the environment by eliminating those factors that serve as triggers for problem behaviors.

Applied behavior analysts must take environmental changes into account to provide the individual with a more comprehensive approach. ABA therapies may be focused on:

  • Providing the individual with reinforcement when performance and response goals are met
  • Establishing a strong connection between compensatory behaviors and consequences
  • Providing a great deal of positive reinforcement while minimizing negative reinforcement

Traditionally, ABA therapy for those with TBIs has been focused on changing maladaptive behaviors, although more recently, ABA has been shown to be an effective treatment for relearning ADLs, such as self-care.

Differential Reinforcement

Differential reinforcement is one of the most widely used ABA techniques for individuals with brain injuries. The goal of differential reinforcement is to positively reinforce the desirable behavior that will eventually replace the undesirable behavior.

The American Academy for the Certification of Brain Injury Specialists’ Training Manual for Certified Brain Injury Specialists recognizes four types of differential reinforcement for the treatment of brain injuries:

  • Differential Reinforcement of Other Behavior (DRO): The individual receives a reward for specific periods of time during which the undesirable behavior does not occur.
  • Differential Reinforcement of Incompatible Behavior (DRI): The applied behavior analyst identifies and reinforces a behavior that is incompatible with the undesirable behavior. For example, rewarding an individual who is able to keep his hands in his pockets instead of touching others.
  • Differential Reinforcement of Alternative Behavior (DRA): Ignoring the undesirable behavior while reinforcing a behavior that takes its place.
  • Differential Reinforcement of Low-Rate Behavior (DRL): Implementing a plan that involves lowering the frequency of a specific behavior. DRL takes into account that a persistent undesirable behavior cannot simply stop, so slowly lowering the rate at which the behavior takes place is more realistic.

Advanced Certification Opportunities for Applied Behavior Analysts Specializing in the Treatment of Individuals with Brain Injuries

The Brain Injury Association of American (BIAA) has established the American Academy for the Certification of Brain Injury Specialists (AACBIS) to recognize behavior analysts and other professionals working with individuals with brain injuries who have attained an advanced level of competency.

To earn certification as a Certified Brain Injury Specialist (CBIS), candidates must demonstrate their learning by taking an examination that covers the following domains:

  • Traumatic brain injury and diagnostic imaging
  • Traumatic brain injuries in pediatrics and adolescents
  • Aging with a brain injury
  • Concussions and traumatic brain injuries
  • Rehabilitation philosophy, outcome measurement, and care management
  • Cultural, gender, and sexuality issues
  • Neuropsychology
  • Physical, medical, neurobehavioral, cognitive, and psychosocial consequences of injury
  • Military populations
  • Effect of injuries on families
  • Participation and return to work

The examination also includes a section on real-life scenarios that requires candidates to apply their knowledge to clinical situations. To become certified, candidates must score an 80 percent on the exam and attend one online training session via telephone.

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You can learn more about AACBIS certification here.

Additional Resources for Information on Promoting Rehabilitation and Independent Living with ABA

The Association for Behavior Analysis International (ABAI) has a special interest group on Rehabilitation and Independent Living that is focused on behavior analysts who provide ABA services to individuals suffering from a variety of disabilities that result from neurological injuries.

Additional information on treating disabilities related to brain injuries can be found through the Brain Injury Association of America.

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