Treatment of maladaptive behavior in acquired brain injury

Clinical Psychology Review, Vol. 20, No. 3, pp. 405–426, 2000 Copyright © 2000 Elsevier Science Ltd. Printed in the USA. All rights reserved 0272-7358/00/$–see front matter

PII S0272-7358(98)00102-0

TREATMENT OF MALADAPTIVE BEHAVIOR IN ACQUIRED BRAIN INJURY: REMEDIAL APPROACHES IN POSTACUTE SETTINGS Joseph M. Ducharme Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada and University of Toronto

ABSTRACT. 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. © 2000 Elsevier Science Ltd.

KEY WORDS. Behavior therapy, Brain injury, Maladaptive behavior, Functional equivalence, Errorless approaches.

SEVERE MALADAPTIVE BEHAVIORS, including aggressive, destructive, disruptive, and oppositional responses are common sequelae to an acquired brain injury (ABI) (Manchester, Hodgkinson, & Casey, 1997; Persel & Persel, 1995; Wood, 1984; Zahara & Cuvo, 1984). These responses are estimated to occur in a majority of individuals who have experienced severe head trauma (Crosson, 1987). In individuals manifesting chronic problem behavior after an ABI, factors related to neurological damage, cognitive deficits, psychological sequelae, environmental contexts and premorbid beCorrespondence should be addressed to Joseph M. Ducharme, Department of Human Development and Applied Psychology, Ontario Institute for Studies in Education of the University of Toronto, 252 Bloor Street West, Toronto, Ontario, M5S 1V6, Canada.

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havioral characteristics can play a role in maintaining the behavior (Davis & Goldstein, 1994; Rosenthal & Bond, 1990). Although aberrant responding may spontaneously decrease during recovery, there are often serious behavioral sequelae in the postacute environment after medical conditions have been stabilized (Eames, Haffey, & Cope, 1990; Manchester et al., 1997). Substantive recent advances in medical research and technology have been associated with dramatic increases in survival rates for persons with ABI (Brooks, Gabella, Hoffman, Sosin, & Whiteneck, 1997; Clifton, 1997). Experimentally rigorous studies evaluating treatment of severe behavioral sequelae in ABI, however, have been relatively sparse (Cope, 1995; Franzen, 1991; Kehle, Clark, & Jenson, 1996). This paucity of systematic clinical evaluations can be attributed to a variety of factors. One factor relates to difficulties in establishing internal validity of treatments (Barlow & Hersen, 1984; Posavac & Carey, 1997). Given that some spontaneous recovery occurs after ABI, the clinical researcher evaluating interventions often struggles to determine whether treatment procedures or the natural course of healing was responsible for the change (Cassidy, 1994). This is especially true when behavioral treatment occurs within the first year of the injury. This difficulty in establishing experimental control often is compounded by adjunctive pharmacological intervention for treatment of various medical sequelae, such as seizure disorders and psychiatric conditions. Additionally, a person with ABI typically participates concurrently in other types of rehabilitation, such as speech therapy and physiotherapy. These treatment modalities provide another range of confounding variables complicating attribution of change to specific interventions. Difficulty in obtaining subject homogeneity is another common research problem in ABI (Whyte, 1994; Willer & Corrigan, 1994). Simultaneous or even nonconcurrent treatment evaluations of multiple individuals with similar presenting problems are often impossible due to the broad variation in severity and location of brain injuries and the wide variety of behavioral sequelae (Dikmen & Machamer, 1995; Eames et al., 1990; Mateer & Ruff, 1990). Clinical researchers in ABI usually are restricted to case studies and single subject research designs when evaluating interventions (Backman, Harris, Chisholm, & Monette, 1997). Despite such difficulties in empirical validation, many clinicians in ABI have embraced behavior therapy for treatment of behavioral disorders. Wood and his colleagues (e.g., Wood, 1984; Wood & Burgess, 1988; Wood & Eames, 1981) were among the first to document the effectiveness of various behavioral procedures in ABI with a range of problem behaviors. Since that time behavior therapy has gained acceptance as a vital component of ABI rehabilitation (Jacobs, 1993; McGlynn, 1990; Wesolowski & Zencius, 1994). Although growth in use of behavioral approaches in ABI is an essential direction for the field, clinicians and care providers need to be aware that effective, generalized intervention typically requires sophisticated conceptual knowledge of behavior therapy approaches (Wolpe, 1989). In behavior therapy research, independent variables (treatments) are defined operationally for easy replication. Such procedural clarity can lead to the impression that behavior therapy is an assortment of simple techniques that can be used in a cookbook fashion by anyone capable of following prescriptive instructions (Eifert, Schulte, Zvolensky, Lejuez, & Lau, 1997). Treatment providers using behavioral approaches in this manner may focus on the topographical and structural aspects of the problem behavior in an attempt to select a technique for reducing its frequency. Using behavior therapy in this manner is reactive rather than proactive and often leads to inadequate treatment and generalization effects and a

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preponderance of aversive procedures (Iwata, Vollmer, Zarcone, & Rodgers, 1993; Meyer & Evans, 1986). Sophisticated behavior therapy requires much more than familiarity with techniques. A thorough knowledge of principles of learning and how they apply to the specific proximal and distal factors maintaining problem behavior is essential (Hayes, 1997; Hayes, Rincover, & Solnick, 1980). Behavioral assessment requires in-depth information about functional relations between environmental contexts and the behavior of the individual (Jacobson, 1997). The remedial approaches described in this article represent conceptually derived interventions based on systematic analysis of variables maintaining the problem behavior, and are focused on skill acquisition rather than problem behavior reduction.

REMEDIAL APPROACHES After an ABI, a large number of factors interact to determine the probability of maladaptive response patterns in the individual (Eames et al., 1990; Mateer & Ruff, 1990). These include premorbid behavior and skill level, the extent and nature of the damage to the brain, and cognitive, psychological, and physical sequelae of the injury. This amalgam of factors often results in decreased life competencies that can impede effective conduction of daily activities and access to desired outcomes. ABI survivors, like most individuals in society, have common needs and goals, such as social interaction, involvement in enjoyable and meaningful activities, and freedom to avoid or terminate situations that they find unpleasant or aversive. Due to their impairments, these persons often develop maladaptive strategies for attaining these goals and producing desired environmental change. They may find that violent or disruptive behavior may be their only option for managing the environment when communicative, social, self-control or other skills are compromised (Manchester et al., 1997; Treadwell & Page, 1996). Most chronic, post-ABI behavior problems can thus be conceptualized as outgrowths of skill deficits. Regardless of the cause of the behavior problem or the conditions associated with it, individuals with ABI typically will benefit from learning or relearning skills that allow them to manage everyday events and interact with others effectively (e.g., Hart & Jacobs, 1993; Wood, 1990). Remedial approaches can be used to increase socially adaptive skills or capabilities in persons responding to the environment in maladaptive ways. Such skill training strategies have become the sine qua non for treatment of severe problem behaviors. The skills learned provide ABI survivors with the ability to manage the environment more independently, and reduce the need for external control and maintenance by others (Blackerby & Gualtieri, 1991; Wesolowski & Zencius, 1994). The remedial approaches considered here have been investigated with a wide range of populations, including adults, adolescents and children with behavioral, developmental and psychiatric disorders. Although adaptation of these approaches to behavior problems in ABI is still nascent due to the above described impediments to rigorous treatment research, there is increasing research and clinical evidence that they can be employed to optimal effect with this population (e.g., Pace, Ivancic, & Jefferson, 1994; Peters & McLean, 1995; Slifer et al., 1997; Treadwell & Page, 1996). In this paper, I will discuss two primary subcategories of remedial procedures: A. Functional equivalence approaches and B. Errorless remediation. It is important to note that remedial approaches generally are appropriate in the post-acute environment, when the individual with an ABI has been medically stabi-

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lized and transferred to a rehabilitation setting. At this time the individual is less confused and amnesic and will benefit from treatment approaches that provide training in compensatory skills that can replace maladaptive responses. Some components of remedial approaches, such as differential reinforcement (Jones & Baker, 1990; Poling & Ryan, 1982), may be necessary to assist in behavior management in the acute environment (Slifer, Cataldo, & Kurtz, 1995; Slifer et al., 1993). In general, however, the use of skill-teaching approaches is premature under most acute conditions, because of fluctuating arousal and medical status. Another class of behavioral procedures often used in the field of ABI, which I have referred to as moderating approaches (Ducharme, in press), can be used when maladaptive behavior is severe enough to make skill training difficult or even dangerous. They can produce a short-term abatement of problem behavior that opens windows of opportunity for using remedial approaches. Care providers can employ these approaches to manage severe behavior and make the environment more tolerable until the individual is ready to learn new skills to replace maladaptive responses. Moderating procedures include: (a) withdrawal of discriminative stimuli controlling maladaptive behavior; (b) ecological approaches (i.e., manipulation of less proximal conditions that may affect behavior, such as physiological factors related to internal states or emotional variables); (c) behavioral rapport (an interaction style that enhances cooperation and de-escalates agitation); (d) pharmacological approaches (use of medications to temporarily moderate problem behavior); and (e) decelerative consequences (punishment approaches that decrease the frequency of the behavior they follow). Moderating approaches are useful in the acute environment, when the individual’s behavior may be highly volatile and unpredictable due to neurological instability, disorientation, and post-traumatic amnesia (Howard, 1988; Sandel & Mysiw, 1996). These procedures can help to assuage these unstable conditions and decrease the probability of severe and dangerous episodes until further healing and recovery has occurred. Moderating approaches are not designed to teach new skills, but to make the environment more controlled and tolerable to all individuals occupying it (Ducharme, in press). Because remedial procedures are essentially sophisticated teaching procedures, there is little potential for abuse of these techniques. In contrast, some moderating approaches, specifically pharmacological approaches and decelerative consequences, must be used with caution. These procedures may have negative side effects and should always be accompanied by sophisticated use of skill-building strategies (Jacobs, 1993; Meyer & Evans, 1986).

FUNCTIONAL EQUIVALENCE One of the foundations of operant conditioning is the tenet that most responses exhibited by individuals are developed and maintained by the consequences that follow them (Skinner, 1938, 1953, 1974). Consequences that maintain or increase the probability of behavior are referred to as reinforcers or functions and can occur in the form of positive or negative reinforcement. Positive reinforcement increases the probability of a behavior through the delivery of a desirable stimulus situation (e.g., social interaction, food, enjoyable activity) after the response. Negative reinforcement increases the probability of a behavior through the occurrence of avoidance or escape from undesirable situations (e.g., unpleasant social situations, overstimulation, difficult demands) contingent on the exhibited behavior.

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After an ABI, an individual may have extreme difficulty attaining even the simplest goals due to deficits resulting from the injury. Impairments may include cognitive and neurological deficits, such as impaired auditory and visual perception, memory deficits, impairments of language comprehension, formulation and production, impaired abstract reasoning and problem-solving, reduced social perception, impulsivity, and disinhibition (Luria, 1973; Whyte & Rosenthal, 1993). Physical impairments that often accompany ABI, such as paresis, spasticity, rigidity, loss of coordination, fine motor skill deficit, or tremor (Gowland & Gambarotto, 1994) can also result in difficulty and discomfort during attempts to access desired outcomes. Skill deficits comprising a specific injury may result in confused, frenzied, or frustrated attempts by the person to deal with everyday circumstances and fulfill needs. Some of these attempts may be maladaptive, crude, and inefficient (e.g., aggression, destruction), but may eventually produce desired results (increased attention from others, access to desired objects, activities or foods, reduction in level of demand, etc.). The aberrant response therefore becomes purposeful or functional for the individual. Under such circumstances, the probability of response recurrence is substantially increased (Treadwell & Page, 1996).

A Case Example A brief case description may help to illustrate this concept. Vito had minor problems with anger control prior to his car accident and brain injury. Although he was able to function effectively under most premorbid conditions, his injury left him with a wide range of deficits. These included paresis of his left arm, expressive language difficulties, problem-solving deficits, increased impulsivity and even greater difficulty in managing anger and frustration. Under this complex set of changes, Vito found that completing a shower was an extremely challenging and uncomfortable task. Requests to shower with assistance of a staff person therefore became highly aversive stimuli. Vito also found that his subtle attempts to avoid the shower (e.g., shaking his head at the staff person or remaining in bed and ignoring the request) were ineffective or not correctly interpreted. The interaction of these multiple factors resulted in a physically aggressive response when the care provider persisted in issuing the request. The aggressive response resulted in the desired reduction of stimulation and demands for Vito, as the care provider made no additional requests and quickly departed to avoid further confrontation. Although Vito was restricted to a narrow range of potential responses to reduce undesired social interactions and demands due to his ABI, his aggressive response was highly effective at achieving the desired outcome. The future probability of aggression, which initially occurred in response to a range of internal and external factors, was thereby increased, due to its effectiveness in providing escape from an unpleasant situation. To further illustrate the functional nature of problem behavior in ABI, we can describe another set of circumstances involving the same client. Vito had been a very social person before his ABI. He had many friends with whom he would interact often. When they met Vito in his postinjury state, his friends were uncomfortable with the dramatic changes in his personality and functioning level and gradually stopped coming to visit him in the rehabilitation hospital. Vito had dated frequently before his accident, but now was unable to develop even friendly acquaintances with other females in the hospital because of his short temper

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and poor communication skills. He thus found himself without a supportive social network. Although he had rehabilitation activities scheduled into his day, Vito had few opportunities for quality interaction or physical contact with staff or other patients. In a frustrated attempt to initiate social or sexual contact, Vito grabbed one of the female staff around the waist and fondled her breasts. The frightened scream of the staff person led to the appearance of a crisis response team of two male staff. They grabbed Vito on either side, pulled his arms away from the female staff and held him in manual restraint until he stopped struggling. He was then released and guided to his bedroom where the crisis response staff sat and talked to him about the importance of refraining from touching female staff. These incidents began to occur more frequently. Vito had learned that the only way to access sustained social attention or physical contact was to grab one of the female staff, because he no longer possessed the skills to access social contact in a more appropriate manner. Not only did the aggression led to an arousing sexual encounter, but also resulted in an extended period of physical and verbal interaction from the staff who restrained him. Although these interactions were not as desirable as social situations Vito accessed premorbidly, they were more rewarding than the extended periods without any form of social contact that he had been experiencing since his injury. This case example illustrates that the environment, especially the social environment, begins to play an important role in ensuring that maladaptive behavior exhibited by a person with ABI continues to occur. Although the initial behavioral difficulties may be catalysed by neurological damage, cognitive and communicative deficits, and confusion, the maladaptive response can become functional, providing an effective means of interacting with the environment.

Functional Equivalence Defined Functional equivalence (Carr, 1988; Horner & Day, 1991) is a behavioral concept describing access of the same function or reinforcer by means of two or more topographically different responses. The two responses are considered functionally equivalent because they both lead to delivery of the same class of reinforcement. This concept is essential to treatment of maladaptive behavior that has become functional or outcome-oriented, as in the above case study. By conducting a behavioral assessment of the aberrant responding, the clinician can obtain information about the function served by the behavior and the range of potential variables maintaining the problem. The individual can then be taught a functionally equivalent, socially adaptive skill (i.e., one that provides access to the same function). If the individual learns that this adaptive response is more likely to lead to the desired class of reinforcement, the new behavior will increase in probability and render the maladaptive response unnecessary (e.g., Carr & Durand, 1985; Northrup et al., 1991). In the current context, I will use the label functional equivalence to describe a range of interventions derived from an assessment of the function or desired outcome of the problem behavior. These treatment approaches involve teaching adaptive skills that provide access to the same functions previously attained with problem behavior. Such skill training strategies have been validated with various behaviorally disordered populations (e.g., Durand & Carr, 1991; Koegel & Frea, 1993; Sprague & Horner, 1992) and recently examined with brain-injured individuals (Treadwell & Page, 1996).

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Assessment of Behavioral Function Assessment of function is completed through systematic observational analysis of the individual, in conjunction with interviews with significant persons in the client’s life (Derby et al., 1992; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982; O’Neill, Horner, Albin, Storey, & Sprague, 1990; Steege, Wacker, Berg, Cigrand, & Cooper, 1989). The observer collects data on frequency, intensity, and duration of the behavior, conditions that precede or overlap with the behavior, and outcomes achieved by the behavior (Foster, Bell-Dolan, & Burge, 1988; Mace, J. S. Lalli, E. P. Lalli, & Shea, 1993; O’Neill et al., 1990). Observations can be done in naturalistic situations or under analogue conditions that have been contrived to examine specific circumstances associated with the problem behavior (Mace & J. S. Lalli, 1991). The purpose of all observations is to develop or empirically validate hypotheses about potential functions or maintaining variables. The care provider or clinician typically compiles all observational information to determine consistencies in conditions associated with problem behavior occurrences.

Choosing Functionally Equivalent Skills Once the assessment is completed and hypotheses about behavioral function are developed, the clinician must determine what adaptive skills to teach that will allow ready access to the desired outcome being attained by the problem behavior (Dunlap, 1993). The three most comprehensive categories of functionally equivalent skills relevant to ABI are communication skills, social skills, and cognitive skills. Communication skills. ABI survivors often suffer serious diminution of communicative abilities (DePompei & Blosser, 1991; Hartley, 1995). These losses can lead to unsuccessful communication attempts and, as described in earlier examples, can result in aberrant attempts to meet communication goals. Functional communication training (e.g., Carr & Durand, 1985; Carr et al., 1994; Durand, 1991; Durand & Carr, 1991; Shirley, Iwata, Kahng, Mazaleski, & Lerman, 1997) is a form of functional equivalence that involves teaching a communicative alternative to the problem behavior. An individual who has learned that aggression results in the termination of a challenging activity, and therefore uses aggression to attain this outcome, could be taught a communicative response that informs the care provider “I am tired; I would like to stop now.” If the care provider then terminated the activity (i.e., provided the desired outcome), the individual would likely use the communicative response more frequently in the future and the aggressive response would no longer be necessary. Functionally equivalent communicative responses do not need to be complex. They must be easily interpretable, however, by those in the individual’s environment. It is also important to note that the trained response does not have to be verbal, as many individuals with ABI have severe communication impairments. A wide range of alternative communicative forms exists, including gestures, facial expressions, signs, traditional orthography (e.g., handwriting, picture-drawing), symbol boards, and simulated voice systems. There is a preponderance of studies examining use of behavioral approaches to retraining speech and language functions in ABI survivors with communication disorders, such as aphasia (McGlynn, 1990). There are also a few studies examining behav-

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ioral approaches to modifying inappropriate communication and conversational skills in individuals with ABI (e.g., Alderman & Burgess, 1990; Giles, Fussey, & Burgess, 1988; Lewis, Nelson, Nelson, & Reusink, 1988). Use of functional communication training to reduce severe behavioral sequelae to an ABI has been evaluated in only one investigation (Treadwell & Page, 1996); however, although this approach has been recommended recently in the ABI literature (Ylvisaker & Feeney, 1994; Ylvisaker, Feeney, & Szekeres, 1998). In the Treadwell and Page (1996) study, a 3-year-old boy diagnosed as brain-injured after meningitis was assessed to determine the function of his aggression, self-injury, and property destruction. The investigators determined that positive reinforcement, in the form of access to social interaction and toys, was maintaining aberrant responding (i.e., care providers were inadvertently providing access to these reinforcers when problem behaviors were exhibited). During treatment, the authors taught the child one-word responses that could be used to communicate the desire to access the reinforcers. When the child used the newly trained responses, contingent access to interaction and toys was provided, resulting in concomitant decreases in problem behavior. Thus, the child’s maladaptive behavior ceased to be functional or necessary when a more socially adaptive and efficient response was made available to achieve the desired outcome. Social skills. Many of our everyday experiences involve interactions with other individuals. Throughout our life span we gradually develop and hone our ability to make social interactions productive and rewarding. Our social skills allow us to develop meaningful relationships, to elicit desired responses from others, to meet societal goals in the home, school and workplace and to courteously terminate undesirable interactions with others. After an ABI, social interaction is often severely impaired (Flanagan, McDonald, & Togher, 1995; Ylvisaker, Urbanczyk, & Feeney, 1992). As with communication skills, when social skills are compromised after an ABI, the individual often uses maladaptive strategies in an attempt to gain access to desired social outcomes. Teaching social skills to mitigate behavior problems is another form of functional equivalence (Frea & Hughes, 1997; Koegel & Frea, 1993). After determining that the problem behavior is directed at a specific social function, detailed observation and analysis of the individual while engaged in social interaction are required. These can be done through naturalistic observation or in contrived role-play situations. Such observations allow the clinician to determine the level of social skill currently possessed by the individual and isolate those skills that require training or retraining (Bellack, Mueser, Gingerich, & Agresta, 1997; Brotherton, Thomas, Wisotzek, & Milan, 1988). The range of social skills that may require training for individuals with ABI is diverse (Boake, 1991; Smith & Godfrey, 1995). Depending on the specific curriculum being used (most social skills training programs used in ABI have been adapted from those used with other populations), training programs can focus on such skills as assertiveness, social problem-solving, empathy, cooperation, conversational skills, and conflict management (e.g., Bellack et al., 1997; Goldstein, 1988; Goldstein, Sprafkin, Gershaw, & Klein, 1980). For effective skill training, however, it is essential that these categories be broken down into operationally defined response clusters that can be taught using performance-based training procedures (e.g., Bellack et al., 1997). A few studies examining the training of skills to improve complex social interaction have appeared in the ABI literature (i.e., Braunling-McMorrow, Lloyd, & Fralish, 1986; Broth-

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erton et al., 1988; Helffenstein & Wechsler, 1982). None of these investigations, however, used maladaptive behavior as a dependent measure to demonstrate covariant decreases in severe problem behavior after enhancement of social functioning. Cognitive skills. Cognitive deficits are one of the most common sequelae to ABI and are associated with many of the difficulties encountered during and after rehabilitation (Gordon & Hibbard, 1991). Common impairments targeted for intervention include memory, attention, concentration, cognitive problem-solving, and planning skills (McGlynn, 1990; Wesolowski & Zencius, 1994). Individuals with deficits in these areas after an ABI are likely to encounter difficulty in carrying out even simple functional activities, such as using a bank machine, making a grocery list, or preparing a meal. Failure of ABI survivors to attain such outcomes, especially when under duress from individuals who are unaware of the need to moderate postmorbid expectations, can lead to problem behavior (Ylvisaker, Feeney, & Szekeres, 1998). Thorough assessment of cognitive skill deficits requires collaboration between all involved professionals, including neuropsychologists, behavioral psychologists, speech language pathologists, and occupational therapists. Such assessment must be ongoing, due to the sometimes constantly changing cognitive status of individuals with ABI, and contextualized, to ensure that assessment results are representative of the day-to day functioning of the individual (Ylvisaker & Gioia, 1998). Once cognitive deficits have been determined, the clinician must assist the individual in achieving real-world goals by developing strategies for retraining the skills, teaching the individual to use compensatory strategies, and ensuring appropriate environmental supports (Ylvisaker, Szekeres, & Haarbauer-Krupa, 1998). Emerging evidence suggests that, as with communication and social skills training, cognitive skill training should be integrated into the teaching of functional skills (as opposed to training of discrete cognitive processes and components) and implemented in naturalistic rather than artificial contexts (Hartley, 1995; Valletutti & Dummett, 1992; Ylvisaker & Szekeres, 1998). Although the teaching of cognitive skills is a mainstay in brain-injury rehabilitation, no empirical studies have yet been conducted demonstrating a relationship between cognitive skills training and aberrant behavior reduction.

Teaching Functionally Equivalent Skills The goals of intervention with any functional equivalence approach are (a) to teach the equivalent response or skill, (b) prompt the individual to use the skill under conditions in which the aberrant response would typically have occurred, (c) ensure that the desired outcome is attained immediately afterwards, and (d) ensure that socially maladaptive responses do not continue to provide the most effective access to desired outcomes. The key to effective use of functional equivalence is to teach the individual a more efficient response or strategy for accessing outcomes (Carr, 1988). Most persons will select and use the simplest and most response cost-effective means of attaining important outcomes in their life. As long as aberrant behavior provides the most immediate access to desired reinforcers for ABI survivors, they will continue to exhibit socially maladaptive response patterns. Clinicians, therefore, need to select functionally equivalent responses that provide equal or more efficient access to outcomes. For this reason, response simplicity may be essential to treatment effectiveness in the initial stages of functional equivalence intervention. In most cases, clinicians can arrange conditions to demonstrate that simple socially adaptive responses

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and response clusters can be effective with less response-cost than most maladaptive behaviors. There are several different techniques essential to a functional equivalence approach. These include a range of behavioral strategies that have been extensively validated in ABI, such as differential reinforcement (e.g., Alderman & Knight, 1997; Slifer et al., 1993, 1995; Wood, 1988), shaping (e.g., Katzman & Mix, 1993), and prompting (e.g., Giles & Clark-Wilson, 1988; Zencius, Wesolowski, Burke, & McQuade, 1989) techniques. Performance-based training approaches such as modelling, role-playing, and performance feedback are also necessary and have been used with brain-injured individuals to teach new skills (e.g., Alexy, Foster, & Baker, 1983; Gajar, P. J. Schloss, C. N. Schloss, & Thompson, 1984). In addition, extinction is an essential addendum to effective use of functional equivalence (Ducharme & van Houten, 1994; Iwata et al., 1993; Shirley et al., 1997). Extinction involves withdrawal of reinforcement for a response that was maintained by that reinforcement, producing an eventual reduction or termination of the response. When clinicians use functional equivalence procedures, they teach the client an alternative and adaptive strategy for accessing reinforcement. As the new behavior is being taught, the clinician must ensure that the maladaptive behavior is no longer functional. If the individual continues to access desired outcomes by exhibiting maladaptive responses, there will be little motivation to learn socially adaptive behaviors. Use of extinction ensures that reinforcement is no longer available when the individual exhibits aberrant responses. There are two commonly used extinction strategies. With extinction of positively reinforced behavior, care providers prevent access to social interaction, tangible rewards, or activities whenever the problem behavior occurs. With extinction of negatively reinforced behavior, care providers continue to involve the individual in activities for short durations after maladaptive responses directed at task termination. This procedure, sometimes referred to as escape extinction, provides a therapeutic alternative to allowing the person to access escape immediately after the problem behavior, which would likely strengthen the maladaptive response (Iwata, Pace, Kalsher, Cowdery, & Cataldo, 1990; Iwata, Pace, Cowdery, & Miltenberger, 1994). Extinction approaches for reduction of severe problem behavior after functional assessment have been used effectively in the ABI literature (e.g., Manchester et al., 1997; Treadwell & Page, 1996). As with most interventions used to treat behavioral sequelae of ABI, there currently is a dearth of systematic investigations of treatments based on functional equivalence in the ABI literature. This approach, however, has rapidly become one of the treatments of choice for severe maladaptive responses in many other behaviorally disordered populations, and requires more extensive and rigorous evaluation in ABI.

ERRORLESS REMEDIATION As noted above, many individuals with ABI exhibit maladaptive behavior when exposed to specific sets of conditions that most people can abide without difficulty, such as complex social situations or demanding tasks (Iwata et al., 1982; Weeks & GaylordRoss, 1981). When required to complete a self-care task or take part in a necessary physiotherapy session, for example, a person with ABI who has difficulty tolerating demands due to cognitive and neurological impairments may resist or become aggressive. Using a functional equivalence approach, the clinician would attempt to teach

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the individual to exhibit socially adaptive behaviors that provide access to the same outcomes as were attained through aberrant responding. Thus, the clinician might train the person to demonstrate an appropriate communicative response that clearly indicates a desire to terminate the physiotherapy session. By teaching an alternative response that provides escape from an undesirable situation, or alternatively, allows the person to gain immediate access to a reinforcer that is not typically available, however, the clinician may inadequately address the individual’s true problem. In many post-ABI situations, care providers cannot honor all appropriate requests to terminate an activity or provide reinforcer access. There are many activities and demands that the person with ABI must complete to maintain cleanliness and health and to benefit from rehabilitation. They also may need to learn to be patient or to tolerate the absence of desired outcomes under circumstances in which those outcomes are not naturally available. Given that many individuals with ABI have problems related to poor self-esteem, anxiety, and depression (MacNiven & Finlayson, 1993; Newton & Johnson, 1985), they may be inclined to view challenging activities as aversive and attempt to avoid them. If requests for termination are always effective, such requesting will likely increase substantially (Carr et al., 1994), and engagement in self-care and rehabilitation activities will suffer. Impulse control and impatience issues are similarly commonplace with this population (Whyte & Rosenthal, 1993). Providing impulsive individuals with immediate access to requested outcomes that they would normally have to wait for could actually reinforce impulsive responding. It is, therefore, additionally necessary to teach persons to tolerate conditions that they may have difficulty abiding (Carr et al., 1994; Fisher et al., 1993; Fowler & Baer, 1981). Through use of systematic graduated introduction of problem conditions, clinicians may be able to reduce aberrant escape and avoidance responses, thereby decreasing the aversiveness of difficult circumstances for individuals with behavioral difficulties and impulsivity. Errorless remediation involves strategies for teaching individuals to tolerate difficult everyday conditions, thus alleviating problem behavior associated with these conditions. The errorless approach to behavioral remediation is based on errorless discrimination teaching approaches developed by behavioral researchers in the 60s (e.g., Stoddard & Sidman, 1967; Terrace, 1966; Touchette, 1968). In errorless teaching, difficult discriminations are simplified through the use of prompts during the initial phases of teaching. These prompts are gradually faded over time, exposing the learner to increasingly more challenging discriminations. The rate of prompt fading is slow enough to ensure that no (or few) errors occur. After training, the learner is able to respond correctly to discriminations that posed difficulty prior to teaching. The learner experiences a much lower error rate with the errorless approach than with trial-and-error approaches (Duffy & Wishart, 1987; Gold & Barclay, 1973; Richmond & Bell, 1983; Wilson & Evans, 1996). Errorless remediation is analogous to errorless teaching. Socially maladaptive behaviors exhibited by the individual are treated like errors, and the clinician arranges the environment to ensure the lowest possible level of these problem responses throughout treatment. This process requires a careful assessment of all stimulus conditions associated with aberrant behavior. Through observation of the individual in naturalistic situations, the clinician isolates situations that correlate with maladaptive responses (Touchette, MacDonald, & Langer, 1985). The clinician then reorganizes the environment during the initial

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stages of treatment to ensure that maintaining conditions are withdrawn (e.g., Ducharme & Popynick, 1993; Ducharme, Pontes, et al., 1994; Pace et al., 1994), or are presented in an altered form that reduces maladaptive response probability (e.g., Ducharme, Lucas, & Pontes, 1994; Ducharme & Worling, 1994). The clinician gradually reintroduces maintaining conditions in a hierarchical progression at a slow enough rate to ensure that maladaptive behavior and ancillary emotional responses remain at low or near-errorless levels. Throughout this process, the adaptive behavior of the individual is reinforced in the presence of the increasingly difficult stimulus conditions. By the end of treatment, the individual is able to deal effectively with conditions previously associated with maladaptive behavior (Weeks & Gaylord-Ross, 1981). With the errorless approach, individuals are never exposed to difficult conditions until they have effectively managed milder circumstances to which a successful and socially adaptive response is much more likely. For this reason, severe maladaptive behavior occurs at a low level throughout treatment, often rendering restrictive or punitive consequences unnecessary. There are a wide variety of ABI rehabilitation situations for which errorless remediation is appropriate. The most obvious application involves teaching individuals with neurological, cognitive or physical deficits to tolerate demand situations correlated with behavior problems, such as rehabilitation and self-care activities (Pace et al., 1994). The approach can also be used to teach persons with impulsivity or difficulty deferring gratification, common sequelae of frontal lobe injuries (Hartley, 1995), to tolerate situations in which reinforcers are absent. Reinforcer absence may be due to the required need to delay, withdraw or deny access to desired persons, foods, activities and objects. This approach has been demonstrated in the non-ABI literature (Fowler & Baer, 1981; Schweitzer & Sulzer-Azaroff, 1988).

Principles behind Errorless Remediation The errorless approach is derived from a procedural integration of several behavioral principles. As with functional equivalence, errorless remediation requires systematic use of differential reinforcement and extinction procedures (i.e., adaptive responses to increasingly difficult stimulus conditions must be reinforced; maladaptive responses in the presence of these conditions should be rendered ineffective for accessing reinforcement). Additionally, the principles of stimulus control and stimulus fading are essential. When a behavior is reinforced in the presence of certain stimulus conditions, and not reinforced in their absence, the behavior is said to come under stimulus control of these conditions (labeled “discriminative stimuli”). The behavior is therefore more likely in the presence of the discriminative stimuli than in their absence (Honig, 1965; 1970; Martin & Pear, 1996; Terrace, 1966). With problem behavior, the aberrant response may be under the stimulus control of a variety of circumstances, such as a request to complete a demanding activity or denial of a desired item or activity. Stimulus fading involves the gradual change of the stimulus controlling a response. After such change, the response will eventually occur to a partially changed or completely new stimulus (Deitz & Malone, 1985; Martin & Pear, 1996; Pace, Iwata, Cowdery, Andree, & McIntyre, 1993). With errorless remediation, stimulus conditions associated with socially adaptive behavior (e.g., low demand or high familiarity situations) are introduced in the beginning of treatment. The stimulus fading process involves the gradual alteration of these stimuli over several days or weeks to approximate stimulus conditions that had been associated with aberrant behavior before treatment. Due to adjunctive use of reinforcement for socially adaptive responses throughout this graduated process, these altered

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and more demanding stimulus conditions eventually become associated with socially acceptable behavior. If the fading process is completed successfully, the individual can be exposed to these difficult circumstances with no return to aberrant responding.

Empirical Support for Errorless Remediation Several research studies demonstrating effectiveness of errorless remediation of severe problem behavior have recently appeared in the treatment literature. It should be noted that most of these studies have been conducted with non-ABI populations. We conducted one such investigation (Ducharme, Lucas, & Pontes, 1994) with a 5-yearold child with autism. The child exhibited severe self-injury when exposed to specific “problem” teaching tasks (i.e., teaching of prepositions and possessives; interactive play with toy figurines). During one tabletop activity (labeling picture cards), however, she exhibited little self-injury. We used this activity during treatment to “moderate” the effects of the problem tasks. In a multiple baseline across the three tasks, we initially embedded short durations of problem tasks into longer durations of the moderating task (e.g., 8 minutes of moderating task; 2 minutes of problem task). Such embedding resulted in a substantial reduction of the self-injury during the portion of session time allotted to the problem tasks. Over several sessions, we gradually increased the proportion of problem task to moderating task. This fading process was conducted at a slow enough rate to maintain low levels of self-injury. Maladaptive behavior was substantially reduced for each task, even after the moderating task was completely faded. Covariant increases in on-task behavior and correct discriminations were also noted. We partially replicated this study with a brain-injured adult with similar findings (Ducharme, 1997). The woman had experienced left-temporal damage after a lobectomy performed to manage cerebral edema caused by a fall down stairs. She exhibited bouts of severe physical and verbal aggression, particularly in response to certain rehabilitation demands, such as tabletop activities or self-propelling her wheelchair. To build her tolerance to these activities, we initially embedded short durations of these demanding activities into longer durations of activities she tolerated well (being pushed in her wheelchair and being assisted with simple leg exercises). For example, in an early treatment session, she would be asked to complete an easily tolerated activity, such as prescribed leg exercises with manual support (i.e., “lift your foot up to touch my hand”) for approximately 4 minutes. She would then be engaged in an activity typically associated with aggression, such as printing and labeling numbers, for 2 minutes or less, with a switch back to the exercises for about 4 minutes prior to the agitation that typically occurred after longer exposure to the task. We then gradually reduced the session duration of easily tolerated tasks and increased the proportion of session time dedicated to the demanding tasks. The increase in the duration of the demanding activities was completed at a slow enough pace to ensure no return to the baseline levels of the aggression that had been associated with these tasks. Maladaptive behavior in response to the demanding tasks was maintained at low levels throughout treatment, despite the fact that these tasks had been associated with severe aggression prior to embedding. Due to severe medical complications requiring transfer of the patient to another hospital, however, we were unable to complete the final stages of treatment. Pace et al. (1994) used a treatment technique that included the most relevant components of errorless remediation with an individual who had sustained a traumatic brain injury in an automobile accident. The person made obscene verbalizations

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when exposed to task demands (e.g., “put on your shoes”). During treatment, the investigators initially engaged the individual in conversation and removed all task demands. They increased the number of task demands gradually over several sessions. By the end of treatment, the authors substantially reduced obscenity even during presentation of frequent task demands. Kennedy (1994) used a similar intervention to decrease problem behavior in students with developmental disabilities. Another promising treatment for socially maladaptive behavior in this category is errorless compliance training (Ducharme & Popynick, 1993; Ducharme, Pontes, et al., 1994; Ducharme, Popynick, Pontes, & Steele, 1996; Ducharme, 1996), a strategy for reducing oppositional responses and improving compliance with demanding tasks. Given that persons with ABI are particularly prone to difficulties with initiation and motivation (Hopewell, Burke, Wesolowski, & Zawlocki, 1990), interventions to increase compliance with rehabilitation and other important activities are essential. We have evaluated errorless compliance training with a variety of child populations (e.g., developmental disabilities, conduct disorders, witnesses of family violence), and are currently investigating variations of this approach with individuals with ABI who exhibit maladaptive behavior in response to requests to initiate necessary tasks. To implement this intervention, the clinician conducts observations of a broad range of everyday compliance situations with the client and care provider to determine the probability of compliance to requests to complete specific tasks and activities. The clinician then arranges requests in order of compliance probability and divides them into a hierarchy of four probability levels, from Level 1 (high probability of compliance), to Level 4 (low probability of compliance). During treatment initiation, care providers issue Level 1 requests and provide reinforcement contingent on compliance. No consequence is provided for noncompliance (because requests are already high probability, noncompliance is uncommon). Over several weeks, the care provider sequentially introduces subsequent request levels at a slow enough rate to ensure a high proportion of compliant responses. By the end of treatment, clients typically demonstrate high levels of compliance even to Level 4 requests, which were previously associated with noncompliance and other oppositional responses (Ducharme & Popynick, 1993; Ducharme, Pontes, et al., 1994). With errorless compliance training, the clinician achieves these gains without need for punitive consequences such as time-out, that are a component of many compliance training packages for oppositional children (e.g., Barkley, 1997; Forehand & McMahon, 1981; Roberts & Powers, 1990). Slifer et al. (1997) used a variation of this approach with three adolescents with a recent ABI. Through the gradual introduction of therapeutic demands and the reinforcement of approximations of compliance, the authors were able to maintain therapy attendance at a high level and decrease disruptive behavior. Although there are a few studies such as this documenting effective use of errorless remediation with ABI survivors, the errorless approach, like most other interventions for problem behavior, requires much more extensive empirical validation in the ABI field.

BENEFITS OF REMEDIAL APPROACHES In this article, I have proposed that remedial approaches are an essential form of intervention for severe behavioral sequelae to an ABI in the postacute environment. Remedial approaches have several benefits that warrant their recommended use with this population.

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First, both functional equivalence and errorless remediation approaches involve strategies that provide the individual with increased ability to successfully manage life circumstances. Given that ABI survivors often experience a broad range of physical, cognitive, psychosocial, and functional deficits, their ability to deal with many everyday situations is often impaired. Thus, clinical approaches that involve skill training or tolerance building are crucial. By learning socially adaptive responses for accessing desired outcomes and developing physical and psychological tolerance of everyday circumstances, individuals suffering an ABI will have less need to use aberrant strategies to cope with daily stresses. Second, intervention strategies that focus on increasing the client’s ability to master new situations and that include extensive commendation and acknowledgement for such success may be more likely to lead to enhanced self-esteem than approaches focused exclusively on reducing problem behaviors. In the field of ABI, depression, and poor self-image are common post-morbid symptoms (e.g., Lezak, 1987; MacNiven & Finlayson, 1993; Newton & Johnson, 1985). These sequelae are at least partially associated with frequent failure of the individual to deal with everyday events due to physical and cognitive deficits. Remedial approaches, which increase the probability of adaptive responses to difficult situations, may expand the individual’s experience with successful management of the environment, thus potentially enhancing self-concept and feelings of self-efficacy in ABI survivors. Third, although substantiating evidence is still not extensive, behavioral approaches involving skill enhancement and tolerance-building should result in greater generalization and maintenance than procedures that are focused on external management of the problem by others (e.g., Horner & Billingsley, 1988). When individuals are provided with skills to self-manage the environment effectively, they are likely to become their own generalization agents. Thus, they can use these skills in new situations and environments (Koegel & Koegel, 1988; Stokes & Baer, 1977) and maintain the behavioral improvement over time (Derby et al., 1997; Ducharme et al., 1996; Durand & Carr, 1991). In contrast, behavior change engendered without skill training through external control by others may be less likely to generalize to situations in which external control agents are absent. Fourth, behavior problems in individuals with ABI have often been managed using pharmacological (Goldstein, 1995; Silver & Yudofsky, 1994) or contingent punishment approaches. Such decelerative consequences as timeout (e.g., Goodman-Smith & Turnbull, 1983; Peters, Gluck, & McCormick, 1992; Wood, 1987; Wood & Eames, 1981), required compliance (e.g., Davis, Turner, Rolider, & Cartwright, 1994; Peters et al., 1992) response cost (e.g., Zencius, Wesolowski, & Burke, 1989), overcorrection (e.g., Foxx & Azrin, 1972; Lewis et al., 1986), and contingent restraint (e.g., Jacobs, Lynch, Cornick, & Slifer, 1986; McMillan, Papadopoulos, Cornall, & Greenwood, 1990; Tynan & Pearce, 1990) have all been employed with ABI survivors to reduce aberrant responding. Pharmacological and punishment approaches can be beneficial in reducing severe problem behavior and making the environment more tolerable to clients and care providers, especially when the behavior occurs with such intensity or frequency that therapeutic interactions may be difficult or dangerous. The potential for side effects, however, should be noted for both drugs (Cope, 1987; Weinstein, Seidman, Ahern, & McClure, 1994) and punitive approaches (Coe & Matson, 1990; Martin & Pear, 1996; Meyer & Evans, 1989; Sidman, 1989). Additionally, punishment procedures are viewed by some as less socially acceptable than reinforcement-based approaches (Kazdin, 1980, 1981).

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Use of remedial approaches may preclude the need for intrusive strategies through the development or restoration of the capacities of the ABI survivor to interact adaptively with the social and physical environment. With newly acquired access to prosocial responses for achieving desired outcomes, as is attained through functional equivalence approaches, the individual with ABI should no longer require the less efficient maladaptive behaviors. With errorless remediation, the likelihood of severe problem behavior during intervention is greatly reduced through the initial withdrawal of conditions associated with maladaptive responding, thus substantially reducing the need for behavioral control strategies. By the end of errorless treatment, the individual is often capable of enduring difficult conditions without need for maladaptive escape or reinforcement-seeking responses. Thus, the need for pharmacological or consequence-based control of problem behavior may be substantially reduced. Additionally, remedial approaches typically are not subject to criticisms of acceptability or negative side-effects because they involve systematic and sophisticated use of reinforcement procedures to teach new skills. When intrusive strategies are deemed essential after sophisticated use of nonintrusive approaches has been demonstrated ineffective, pharmacological and punishment procedures are best used in conjunction with or as a prelude to remedial approaches.

SUMMARY Both functional equivalence and errorless remediation approaches are important components of intervention for individuals with ABI in the postacute environment. Functional equivalence strategies can be used when the maladaptive behavior serves a clear function for the individual (i.e., providing access to desirable outcomes; allowing avoidance of undesirable outcomes). By teaching the person an adaptive behavior or skill cluster (e.g., communicative, social or cognitive skills) that allows efficient access to the same function, the clinician decreases the probability of problem responses by rendering the maladaptive behavior unnecessary. Errorless remediation approaches are used when the behavior problem is clearly related to the inability of the individual to tolerate difficult conditions in the environment. With this approach, the individual is initially exposed to easily tolerable conditions with a gradual introduction of increasingly difficult circumstances. Throughout this process, care providers provide reinforcement for the behaviors exhibited as the person successfully tolerates the situation without exhibiting maladaptive responses. Eventually, the most difficult conditions can be introduced with no return to problem behavior. Both treatment approaches involve systematic teaching of more adaptive response patterns, and sophisticated use of these procedures will result in less need for intrusive strategies to manage problem behavior. Use of these approaches in the acute environment is not recommended, as the individual may be medically unstable, confused, amnesic, and unlikely to benefit from sophisticated teaching and rehabilitation efforts. Similarly, Remedial approaches may be unrealistic in the postacute environment if occurrence of the problem behavior appears to be completely unrelated to proximal or distal conditions or is occurring at such a high frequency, intensity, or duration that systematic teaching approaches are dangerous or difficult. In both of these sets of circumstances, moderating approaches (Ducharme, in press) may be necessary to provide short-term alleviation of the problem behavior, thereby enabling effective skill training for long-term change.

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Acknowledgments—The author expresses his appreciation to Terry Spencer, for his comments and assistance with referencing, Mark Bayley, for his comments on an earlier draft, and Patti Leonard and Jay Graydon, for administrative support.

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