NEUROBEHAVIORAL CHALLENGES
POST-BRAIN INJURY AND THE
FUNDAMENTAL ATTRIBUTION ERROR
Dr. David Demarest
Ph.D., CBIST
Neuropsychologist
On With Life
Dave Anders
MS, CCC-SLP, CBIST
Director of Therapy
On With Life
The “to do” list:
- Overview of Behavioral
Programming
- The Behavior Team
- Behavior Meetings
- The Crisis Cycle
- Philosophy for Dignity-Based
Interactions
- Fundamental Attribution Error
- Tips and Insights for Quality
Interaction
- Case Studies
Behavioral Support and
Management
• The Behavioral
Management Handbook
• Behaviors Related to Loss
of Self-Control
• Behaviors Related to
Physical Impairments
• Behaviors Related to
Mood and Thought
Disorders
• Behaviors Related to
Cognitive Impairment
Dignity Team
• Therapy:
– Dr. Demarest,
Neuropsychologist
– Lindsay Vaux, clinical counselor
– Dave Anders, slp
– Alison Lentz, slp
– Lindsay Maltas, pt
– Kelsee Hove, ot
– Megan Ihrke,slp
– Jessica Blough, cota
• Nursing:
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Charis Maldonado, cna
Sherry Mullins, rn
Allyson Emerson, rn
Laura Reedy, cna
Melissa Soukup, cna
Melissa Wyckoff, rn
Breanna Sowle, rn
Ashley McGuire, cna
Bev McKnight, lpn
Ginnie Slings, rn
Alissa Fastenau, cna
Dignity Team Meeting
• Dr. Dave, Lindsay, Dawn, Angie, Sherry,
Dave A., Therapy Representative, CNA
Representative
• Meets every Wednesday 2:00-3:00
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Identify needs
Problem solve & brainstorm
Update dignity plans
Disseminate information to the team
• Let any team member know if behavioral
concerns are noted.
Dignity Plan –
What’s the Concept?
The Crisis Cycle –
Baseline Phase
• This is the individual’s personal best, no
physical or emotional discomfort or distress
• This is the stage at which the individual is best
able to identify deescalation techniques.
• Staff Responsibility – Support the individual in
what they are doing – Proactivity important –
Remember, “Pay me now or pay me later”
The Crisis Cycle –
Trigger Phase
• Something has happened to make
the individual begin to feel
emotionally and/or physically
uncomfortable or distressed.
• Staff Response: Removal from stress
and stimuli
The Crisis Cycle –
Escalation Phase
• The individual is starting to show
increased signs of discomfort or distress.
There may be an increase in breathing,
muscle tension, etc.
• Staff Response: Offer options
(established by you and the individual at
baseline phase), and if needed set
expectations for safety.
The Crisis Cycle –
Crisis Phase
• The individual is now in emotional
and/or physical crisis. Severe or
persistent pain, fear, frustration, anger,
confusion, racing thoughts, delusions.
• Staff Response: Least amount of
interaction necessary for safety
The Crisis Cycle –
De-Escalation Phase
• Physical and / or emotional distress is
still present and the individual may still
use the language of fear and pain,
but some semblance of reasoning has
returned.
• Staff Response: Structured cooling off
The Crisis Cycle –
Stabilization Phase
• The individual has been empowered
to regain some dignity and self
management. The blood pressure,
pulse, and breathing are returning to
normal.
• Active listening, empathy, and support
The Crisis Cycle – Post-Crisis
Drain
• The individual may drop down below
baseline before returning to their normal
status. This is directly related to the
emotional and/or physical intensity
noted during the crisis phase. The
individual may actually be sleepy, or
may appear withdrawn/depressed.
• Staff response: Observation and support
Dignity Plan
Crisis Cycle Phase
PS Responses
Helpful Caregiver Responses
Unhelpful Caregiver Responses
(physical/emotional/cognitive)
Stimulus/Trigger Phase
Known Triggers:

Peri Cares

Staff working in PS’
personal space

Injections

Too many people talking to
him at one time

G-tube cares

Being exposed during cares
/ showers
Give PS a wipe and ask him to participate
Use the phrase “there’s pee” or “there’s poop” to
help him understand why you are in his space
iPad with music or southpark to distract / occupy
him during G-tube cares and injections.
Minimize the amount of time he is exposed. Utilize
towels / stuffers to promote dignity, problem solve
ways to provide for the minimal amount of exposure
possible
Escalation Phase
Yelling out “whoo”
Tenses Body
Asks repetitive questions (i.e.
“what do you want from me?)
Tone of voice becomes more
angry
Perseveration (repeating an idea
over and over)
Physical reactions to touch –
pushing away
Crisis Phase
Swinging, punching, yelling, head- Follow the plan developed prior to entering the
butting,
room
Stop talking
If he is in a safe place, remove yourself from his
personal space and avoid talking.
If he is mid-transfer or in another unsafe position,
guide him to the chair, tilt him back, and remove
yourself from his personal space.
De-escalation Phase
Rushing him. The single most important thing you can do
to help is slowing down.
Having too many people talking at one time
Using too many words to explain…as it is overwhelming to
him.
Be sure you have made a plan prior to the care being Telling him to “stop,” “don’t,” etc.
provided. Each staff should know their role if
Increasing your vocal volume
escalation occurs.
Grabbing, tensing up,
Follow the posted script.
Use “I need” statements
Dodge physical reactions from PS
Use humor.
Allow approximately 30 minutes to de-escalate in a
quiet environment prior to re-attempting
intervention
Physically forcing him
Talking
Re-attempting intervention quickly
Universal Themes for
PS with Agitation
and Aggression
• Prior to entering the PS’ room, caregivers must
develop a plan of action in order to complete the
needed intervention in as safe a manner as
possible. This plan should include:
– Identifying a lead caregiver
– Establishing caregiver roles (zone defense) to maintain PS
and staff safety in the event of escalation through the crisis
cycle
– After establishing the plan, caregivers must assess
themselves, the PS, and the environment.
Debriefing
• After any major neurobehavioral incident, the
team holds a debriefing meeting…goals
include:
– What did the crisis cycle look like?
– Is there an approach/intervention that could’ve
prevented the incident?
– Did we respond in a manner consistent with the
specific Person Served’s dignity plan? If not,
why?
– What did we learn? What would we do
differently if we could have a re-do?
• Debriefings are non-judgmental.
Fundamental Attribution Error
• In brain injury related behavioral
challenges, FAE may be the biggest
barrier to staff maintaining mutually
reinforcing relationships with the people
we serve.
» A fundamental attribution error occurs
when we overestimate how much a
survivor’s behavior can be explained by
internal, controllable characteristics. As we
do this, we fail to adequately consider the
role of situational factors that may be the
cause of the behavior (most importantly,
the brain injury, itself).
FAE Example 1:
SITUATION:
Survivor has a pre-injury
history of obesity and has
been consistently gaining
weight throughout his
stay. Despite staff
education, the PS
continues to request extra
desserts / snacks and
becomes agitated when
his requests are not
honored.
Staff Misattribution
Staff believe that the PS is
“being manipulative”
and that his overeating is
a “bad habit” or related
to poor selfcontrol…which he
obviously had pre-injury
due to his obesity issues.
FAE Example 1:
SITUATION:
Survivor has a pre-injury
history of obesity and has
been consistently gaining
weight throughout his
stay. Despite staff
education, the PS
continues to request extra
desserts / snacks and
becomes agitated when
his requests are not
honored.
Missed Situational Factors:
• The PS’ brain injury has left
him with memory difficulty,
so he forgets that he has
already eaten. In addition,
the brain injury has caused
the PS to no longer have the
sense of being satiated after
a meal, so he constantly
feels hungry.
• Pre-injury thyroid issues were
the primary cause for his
obesity.
FAE Example 2:
SITUATION:
Survivor’s spouse/family have
been asked multiple times to
come in for training and
have not done so.
Misattribution:
Staff feel the family is not
invested in the PS…that
they are self-centered
and are avoiding their
responsibilities.
FAE Example 2:
SITUATION:
Survivor’s spouse/family
have been asked
multiple times to come in
for training and have not
done so.
Missed Situational Factors:
• The family is having financial
difficulty and are having to
pick up overtime in order to
afford gas to drive to OWL.
• Spouse is worried about
losing job. She is having to
spend extra time at work in
order to avoid this.
• One of the PS’ children has
had difficulty coping with the
injury and needs to work with
a counselor. Grades are
declining.
FAE Example 3:
SITUATION:
PS was described as a
“rough character” preinjury. He consistently
swears and yells during
sessions…or refuses
sessions altogether.
Misattribution:
During the team meeting,
staff states “If he wasn’t
being so difficult /
noncompliant, he’d have
some pretty good
potential to improve.”
FAE Example 3:
SITUATION:
PS was described as a
“rough character” preinjury. He consistently
swears and yells during
sessions…or refuses
sessions altogether.
Misattribution:
• The survivor presents with
executive function
deficits…which result in his
difficulty equating the work and
discomfort associated with
therapy to long term
improvement. In addition, the
brain injury has resulted in
heightened pain response and
low frustration tolerance.
• He lost a sibling to cancer and
his mother to an infection she
got while in the hospital…he
does not trust hospitals or
healthcare workers.
FAE Example 4:
SITUATION:
Survivor demonstrates the
physical ability to self-propel to
sessions, but does not do so. In
addition, she states that she
wants to return to college, so
staff have given the PS
appropriate assignments to help
prepare her for school, fill her
time in the evenings and
weekends. She rarely if ever
completes assignments and her
school books remain untouched
on the shelf in her room.
Misattribution:
During the PS conference, staff
refer to the PS as having
difficulty with motivation and
launch into a list of reasons
why the PS needs to do more
self-propelling and complete
more assignments during the
upcoming month to prove she
is really ready for the
responsibilities associated with
college.
FAE Example 4:
SITUATION:
Survivor demonstrates the
physical ability to self-propel to
sessions, but does not do so. In
addition, she states that she
wants to return to college, so
staff have given the PS
appropriate assignments to help
prepare her for school, fill her
time in the evenings and
weekends. She rarely if ever
completes assignments and her
school books remain untouched
on the shelf in her room.
Missed Situational Factors:
• PS brain injury has left her
with deficits in cognitive
organization, initiation and
apathy. The PS possesses
the desire (motivation) to do
what is asked, but has
difficulty organizing her
thoughts and initiating the
tasks.
As the person’s served level of
agitation goes up, you should
counter that with your behavior.
• For example: lower your voice, slow
your movements, convey a calm
demeanor
Tell them what you need them to do rather
than asking them to do things.
•If you ask “do you want to walk?” the
answer will likely be “no.” If this is the PS’
response, and you continue to try to
convince the PS to walk, you now have
added a feeling of disrespect to the
session (they told you that they didn’t
want to walk for crying out loud!)
• Rather than asking whether they want to do
something, use a lot of “I need” statements with this
population. For example:
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“I need you to _________”
“We need you to ____________”
“Your family/husband/son/etc. needs you to ____________”
“The doctor needs you to _____________”
If you want them to stop doing something, speak in
the affirmative rather than in the negative.
– Avoid the use of “don’t,” “stop,” “can’t,”
“no,” etc. If I say to you “whatever you
do…don’t think about ladybugs.” A ladybug
will automatically appear in your mind (it
did…didn’t it?). By using negatives we may
inadvertently be reinforcing the behavior
that we are trying to eliminate.
– Tell them what you want them to do rather
than what you don’t want them to do. For
example, rather than saying, “Don’t pull on
your g-tube.” It would be better to say,
“Keep your hands on your wheelchair/this
Rubik’s cube/this puzzle/the remote”, etc.
Stay one step ahead.
• You need to have multiple options for therapeutic
activity. If you only have one option and the PS shoots
it down, 1 of these 2 things will happen:
• You will continue to push your only option…which will
increase agitation.
• You will abandon your only option…be without a
backup plan…ruin the structure of the
interaction…and increase agitation.
• Anticipate the PS’ need for a break. Movement is one
of the best soothers for this population. The sense that
they are going somewhere is often enough to reduce
agitation. Alternate therapeutic activity with periods
of rolling to a new destination and introducing the
next task.
Shut Up!
•Okay…that may be harsh. What we really
mean is “say what you need to say with as
few words as possible.” This is not dumbing
down your communication…it is shortening
and tightening it. “Normal” conversation is
harder than many think.
•Our knee jerk reaction is to try to
rationalize/reason/use logic to convince the
PS to participate. In most cases, this will serve
to increase agitation because… by
definition…PS at the confused and agitated
level of functioning are not able to access
these skills…particularly during episodes of
agitation.
(Lash & Associates)
Survivors Want Us to
Know…
• I need a lot more rest than I used to. I’m not being lazy. I get
physical fatigue as well as a “brain fatigue.” It is very difficult
and tiring for my brain to think, process, and organize. Fatigue
makes it even harder to think.
• My stamina fluctuates, even though I may look good or “all
better” on the outside. Cognition is a fragile function for a
brain injury survivor. Some days are better than others. Pushing
too hard usually leads to setbacks, sometimes to illness.
• I am not being difficult if I resist social situations. Crowds,
confusion, and loud sounds quickly overload my brain, it
doesn’t filter sounds as well as it used to. Limiting my exposure
is a coping strategy, not a behavioral problem.
(Lash & Associates)
Survivors Want Us to
Know…
• Patience is the best gift you can give me. It allows
me to work deliberately and at my own pace,
allowing me to rebuild pathways in my brain.
Rushing and multi-tasking inhibit cognition.
• Please listen to me with patience. Try not to
interrupt. Allow me to find my words and follow my
thoughts. It will help me rebuild my language skills.
• If I seem “rigid,” needing to do tasks the same way
all the time; it is because I am retraining my brain.
It’s like learning main roads before you can learn
the shortcuts. Repeating tasks in the same
sequence is a rehabilitation strategy.
•
(Lash & Associates)
Survivors Want Us to
Know…
If I seem “stuck,” my brain may be stuck in the processing of information.
Coaching me, suggesting other options or asking what you can do to
help may help me figure it out. Taking over and doing it for me will not
be constructive and it will make me feel inadequate. (It may also be an
indication that I need to take a break.)
•
If I seem sensitive, it could be emotional lability as a result of the injury or
it may be a reflection of the extraordinary effort it takes to do things
now. Tasks that used to feel “automatic” and take minimal effort, now
take much longer, require the implementation of numerous strategies
and are huge accomplishments for me.
•
Don’t confuse Hope for Denial. We are learning more and more about
the amazing brain and there are remarkable stories about healing in the
news every day. No one can know for certain what our potential is. We
need Hope to be able to employ the many, many coping mechanisms,
accommodations and strategies needed to navigate our new lives.
Everything single thing in our lives is extraordinarily difficult for us now. It
would be easy to give up without Hope.
Jane
Crisis Cycle Phase
PS Responses
Helpful Caregiver Responses
(physical/emotional/cognitive)
Stimulus/Trigger Phase
Unhelpful Caregiver
Responses
Positive redirection
Ignoring comments
Social
Assist with communicating to doctors
Ignoring
-Becomes defensive or shuts down
Redirect conversation to positive
-Over explains to justify reasoning
Give two options “___or___”
Passively agreeing (as this may
verify actions with false approval)
-Pushes boundaries
Suggest alone time
Known triggers:
Questioned motives
Childhood memories
Medical issues
Misinterpreted social cues
Escalation Phase
When stressed, she becomes more
of hypochondriac
Saying “do you want to”
Saying “No”, “But”, or “you’re
wrong”
-“You just don’t understand”
Inappropriate Use of Services
Rushing tasks
-increased medical appointments for attention
Demanding
-plays services against each other
Raising voice
-cancels services
Crisis Phase
Social
Encourage her to pick her battles
-calls to report concerns to various authority
(supervisors, managers, police, etc.)
Counteract behavior: talk quieter, make your
movements slower
Trying to reason or assert power
Verbal aggression
De-escalation Phase
-yelling/tone of voice
Passive comments or topic change
Give time and opportunity to express self
Trying to change her
thoughts/ideas
*Do not bring up the topic again,
unless absolutely necessary
Bob
Crisis Cycle Phase
PS Responses
Helpful Caregiver Responses
Unhelpful Caregiver Responses
(physical/emotional/cognitive)
Stimulus/Trigger Phase
Patience- give him time to reflect
Being late
Known triggers:
Give Choices: “Either do seatbelt or stay clean”
Telling him no
Being told “No”
Before services move passenger seat all the way up and
put back seat items up front
Backseat/ Seat belt
Traffic
Touching/talking to kids
Preteach/coach situations discussing socially acceptable
behaviors
Certain Staff
Signing Documentation Sheets
Escalation Phase
Using the word “inappropriate”
Sign documentation sheet at the beginning, confirm
time leaving at the end
Verbal aggression
Redirecting- giving something positive to focus on
-Yelling & Swearing
Not giving choices when he needs to do somethingfollow the plan; use “I need” statements
Grimacing facial expressions
Refusal
Sexual inappropriateness
Mentioning goals
Telling him to “Stop” or “Don’t”
Mention Erik/person in charge
Express personal feelings “I feel bad when you swear at
me and make fun of my driving”
Have a plan B and C if plan A doesn’t work
-Sexual aggression
-Birth control topics
Crisis Phase
Physical Aggression
Staff ends services
Forcing him to do things
-Hitting chairs/seats
Staff takes him home
Trying to reason with Bob.
-taking swings at staff
Counteract his behavior: talk quieter, make you
movements slower
Increased Verbal Aggression
-escalated tone of voice
Calmly give prompts and appropriate choices “Either
____or____”
-increased swearing
De-escalation Phase
Less frequent swearing
Allow Bob to rest
Facial expressions
Talk only when necessary
Do not bring up the topic again,
unless absolutely necessary
Mary
Crisis Cycle Phase
PS Responses
Helpful Caregiver Responses
Unhelpful Caregiver Responses
(physical/emotional/cognitive)
Stimulus/Trigger Phase
Positive redirection (talk about Ace, sister, animals etc.)
Known Triggers:
Talking in a calm voice
-Money/Financial stress
Check to make sure she has her debit card/ checkbook/ money
before going out
-Universal problems ex: spills in the
environment
Patience
-Family dying/ being left alone
Acknowledge conversation, comments and opinions.
-childhood memories
Complements for good behavior, clean apartment, etc.
Escalation Phase
Ignoring comments
Verbal aggression
Redirect conversation to positive
Saying “do you want to”
-yelling\crying
Reassure her that everything will be OK
Rushing tasks
-escalated tone of voice
Validate concerns, “ Why do you think this will happen” without Demanding
having to agree.
Disagreeing
Talk through actions and consequences
Raising voice
Give two options “____or____”
Negative thoughts
-“Doomsday”
-external blame
Suggest alone time
Call her sister
Crisis Phase
Physical aggression
Staff leave early (if in apartment)
Trying to reason
-slams objects down
Counteract behavior: talk quieter, make your movements
slower
*Do not get in her personal space
-Invades personal space
Increased Verbal Aggression
Calmly give prompts and appropriate choices “Either ____ or
____”
-louder yelling and crying
-arguing
De-escalation Phase
Remorseful and apologetic
Allow Jane to rest and reflect for 5-15 minutes
Talk only when necessary
*Do not bring up the topic again,
unless absolutely necessary
The Bottom Line…
• “I've learned that
people will forget
what you said,
people will forget
what you did, but
people will never
forget how you made
them feel.”
– Maya Angelou
Thank You…
• David Demarest, Ph.D., CBIST
• [email protected]
• Dave Anders, MS, CCCSLP, CBIST
• [email protected]