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Chapter 5General Techniques for Working with Individuals with ABI
5.1 - Overview
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Behaviour |
What Not To Do |
What To Do |
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| Verbal perseveration on a single thought. |
Ask the student to stop. |
Redirect his/her to a physical task (e.g., “Could you please hold this book for me while I get a piece of chalk?”). |
Physical
perseveration such
as tapping the desk with his/her hand. |
Ask the
student to stop or physically hold hands still. |
Redirect
student to a verbal task such as engaging him/her with questions
(e.g., “What did you do at recess today?”). |
Student
is overstimulated and becoming angry during recess. |
Tell the student to calm down. Provide negative consequences such as detention or a visit to the principal. |
Redirect
the student to a quieter environment, (e.g., guide her to
another location either through role-modelling i.e., walking
with him and/or inviting her to the other room e.g., “Could
you go and sort the pencils in the storage room?”). |
Student
is unwilling to listen to someone else’s point of view. |
Try to
explain the alternate viewpoint. |
Change
the conversation to an unrelated topic (e.g., “Yesterday
in science class we learned ...”). |
5.3 - Restructuring
Case Study
Anna suffered an ABI as the result of being hit by a car while riding her bicycle. She has made many gains since the injury and has learned several strategies for coping with her deficit. Although doctors say she has problems with her memory, Anna is very expressive and never appears lost for words while discussing her recent activities. Recently, Anna has been having some problems with her friends. Many of them have been calling her a liar and say that she makes up stories. During a recent parent-teacher conference, Anna’s mother confirmed that although parts of the stories Anna tells are true, other parts are not, and that Anna makes up these stories at home as well. Knowing that Anna tends to exaggerate, her teacher began confronting her whenever she began to stretch the truth with the hopes of teaching Anna how to stay with the facts when talking to others. Unfortunately, being confronted only makes Anna upset as she feels her versions of her stories are true. No matter how much time and effort her teacher spends with Anna, trying to correct her stories, the exaggerations continue.
Recently, an alternative approach has been tried which reinforces the truthful parts of the story and allows the student the opportunity to build a more realistic version of events. The strategy has been time-consuming but has helped her restore her credibility with her classmates.
What is Restructuring?
Restructuring is a technique used to guide a person to construct another understanding, perspective, and/or interpretation of an event/thought/belief that will have positively and correctly reflected the events of the situation being discussed.
Possible deficits that restructuring can assist with:
- Confabulation - Verbalizations about people, places, or events that are only partially based on the facts despite the person believing them to be true. Confabulations often result when people with fragmented memories “fill in” missing gaps with details that are not true, but allow for things to make sense and be complete.
- Rigid Thinking - When a person cannot consider multiple influences/variables simutaneously; when a person cannot consider alternative perspectives; in each of these cases, the person will interpret events in a linear fashion and may therefore miss the important subtle factors that can lead to certain interpretations.
- Concrete Thinking - When a person interprets information literally and cannot interpret metaphors, similes, symbolism, or other abstractions.
- Perseveration - When an individual cannot readily consider other ideas, because they are “stuck” on one view.
How does Restructuring Work?
- The strategy works by emphasizing, integrating, and focusing on the relevant and accurate aspects of comments while ignoring or eliminating the inaccurate information or interpretations of statements into what the person is saying. In doing so, the person is not directly confronted about his/ her mistakes, but is guided into telling the correct details of the situation.
- Once the person has generated an inaccuracy, misinterpretation or confabulation, trying to tell him/ her that it is not true will only make it more obvious, memorable and cause him/her to defend it more rigorously, often leading to agitation.
- Oftentimes the best way to handle misinformation is to focus on what was correct about what the person said and reinforce that aspect, then move the conversation to incorporate other correct and valid information in a subtle but definitive manner, (e.g., guide the person to the correct information).
Example of Using Restructuring
While walking to the chalkboard, Tom tripped on a chair leg and fell. Bob helped him up and he was not hurt.
Rick’s response:
"Yesterday Tom was walking up the aisle to sharpen his pencil when he fell and hurt his arm because Bob tripped him."
Tell Rick that his account of the situation is wrong.
5.4 - The “Back Door” Approach
Case Study
Before he suffered an ABI 6 months ago, Esa, a 15-year--old, was very proficient on the computer. Now he has problems learning new applications. When he has problems with new computer applications, he becomes very frustrated, insisting that his failure is the result of a broken computer. As Esa’s frustration increases, the teacher offers to help him with his difficulties. Esa angrily replies “I don’t need help, there is something wrong with the computer, not me, and until it gets fixed, I am not going to use it!”
Disagreeing with Esa only added to his frustration. The teacher has found that a more productive approach is to avoid disagreeing with Esa’s perception of a broken computer and then to offer “new” strategies that will help him to succeed.
What is the “Back Door” Approach?
The back door approach is an expression used to describe interventions that are implemented without the person being aware or confronted, and/or interventions that are compatible with, but not identical to, what the person is doing.
Possible deficits that the “back door” approach can assist with:
- Lack of awareness of deficits - These individuals may not necessarily deny that they were injured, however, they may deny suffering from any long-term effects of a brain injury despite obvious physical and/or cognitive problems. Since they truly believe that they do not have a problem, they do not think they need help and, therefore, are reluctant to accept any kind of assistance.
- Unilateral Neglect - An inability to attend to either the right or left half of their visual field.
- Agnosia - The inability to “know” about or recognize certain types of information, (e.g., object agnosia - can’t recognize certain objects).
Example of the “Back Door” Approach
A student with an ABI is constantly late for class because he cannot cope with the combination lock on his locker. He claims that other students change locks on him.
Insist that the student practice opening the lock until he can get it right.
Agree that it is really hard to be sure that your lock hasn't been tampered with. Then get the student a foolproof special lock with a key. Keep a spare key handy.
5.5 - Positive
Reinforcement (and Differential
Reinforcement or “Catching a Student Doing it Right”)
Case Study
Since his ABI, 11-year-old James has had frequent outbursts of anger at classmates and the school staff, and may throw objects around the classroom. Often the outbursts are directly related to frustration, but sometimes they seem to come out of the blue with no obvious antecedent. Reprimands, isolation, and detentions have failed to reduce the frequency of the outbursts.
As an alternative, the teacher and the educational assistant were encouraged to focus on the times when James is interacting calmly and positively with his environment and recognize these as an accomplishment in the hopes of increasing the frequency of the positive behaviours. It is called “catching the student doing something good.”
What is Positive Reinforcement?
Positive reinforcement is rewarding “wanted” behaviour, thereby increasing the occurrence of the “wanted” behaviour. Simply put, it is letting someone know that what he or she has done is correct, appropriate, and appreciated. It is the best tool to use when trying to increase the occurrence of wanted (desired) behaviours.
Differential reinforcement is using positive reinforcement when the “wanted” behaviour is observed and, alternatively, not responding to any “unwanted” behaviours, oftentimes switching rapidly between two modes.
Possible deficits that positive reinforcement can assist with:
- Lack of self-esteem
- Unproductive behaviours
- Attention deficits
- Memory deficits
Important Considerations
The secret for making positive reinforcement successful is to not overuse the reinforcer and to genuinely mean it when it is delivered. It is also important to discover what reinforcement works for each particular student.
It is important that the reinforcement becomes internalized to the person. The best kind of reinforcement is anything that the student can generate from others by themselves (e.g., a gesture like a smile or a “thumbs up” signal).
Tangible reinforcers such as tokens may work initially, however, when the student is in a different situation where tokens are not available, the behaviour will not be elicited.
Example of how to use Positive Reinforcement
A student is regularly verbally abusive.
Allow the student to receive a significant amount of attention and only reinforce using negative reinforcement. Increase the "wanted" behaviour by having the student try to avoid you responding negatively to them (e.g., criticism).
Use the least intrusive intervention possible to control the verbal abuse. Positively reinforce the student between outbursts for appropriate interactions with classmates and staff.
5.6 - Active
Ignoring
Case Study
Six months ago Liam, while a passenger in his uncle’s car, was involved in a head-on collision. Despite the fact that Liam was wearing a seatbelt, the force of the crash resulted in a blow to the head. Returning to his Grade 10 class, school staff noted that unlike his preinjury behaviour in class, Liam often talks out of turn and speaks out before he has been called upon. These behaviours have resulted in Liam becoming more isolated from his peers (e.g., some students are becoming verbally aggressive at Liam’s behaviour, telling him to “shut up” and/or rolling their eyes when he interrupts). Liam’s teacher has asked him to stop several times and has even tried giving him loss of privilege-type consequences such as staying behind after class. However, these have been unsuccessful and Liam continues to speak out. The in-school team has suggested an “active ignoring” strategy instead. It is felt that a nonverbal, indirect method of responding to Liam’s behaviour, immediately coincident with the occurrence of the behaviour (rather than a delayed consequence) will reduce the negative stigma of being reprimanded in class as well as eliminate any reinforcement caused as a result of gaining the teacher’s attention so frequently. It will permit a procedural, non-judgmental strategy that emphasizes the ineffectiveness of Liam’s current means of participating in class.
What is Active Ignoring?
Active ignoring involves the continued monitoring of a person’s behaviour while deliberately not responding or reacting to it. It is performed in such a way so that unwanted behaviours are not reinforced and, therefore, decrease in frequency.
Possible deficits that active ignoring can assist with:
- Impulsivity, poor judgment, or inappropriate social behaviour
When a student acts out, often the first reaction is to ask the student to stop. If this does not work, more and more time, energy, and attention is given to the event/ behaviour/student in terms of readdressing the behaviour or applying negative consequence until the student stops.
Even though this type of attention is negatively-based and undesirable, the unwanted behaviour is still effective in obtaining attention and/or a response and, therefore, has the potential to be reinforced.
Sometimes the best way to handle unwanted behaviour is to ignore it, however, in an active and deliberate way.
Active ignoring is different from simply ignoring or not paying attention to the behaviour/student, in that you allow the student to know that the behaviour is detected but that you will not react to it (e.g., make eye contact and [subtly] acknowledge the unwanted action, then look away).
This strategy must never be used in a potentially dangerous situation.
Example of How to Use Active Ignoring
Student talks out inappropriately during class.
Verbally reprimand the student in front of the class.
Give the student negative/punishing consequences.
Without stopping the lesson, glance at the student so that eye contact is made and then look away, continuing with the lesson.
Discuss behaviour with student at an appropriate time.
Student repeatedly drops pencil on the floor.
Ask the student to stay after class. Ask the student to pick it up after each occasion.
Look at the pencil on the floor, not the student, perhaps even pick it up to demonstrate that the behaviour was indeed noticed; then continue with the lesson.
5.7 - Cueing
Case Study
Mandeep was an excellent student, maintaining a high academic average in her Grade 6 class. Since experiencing a fall during a school soccer game earlier this year she has had difficulty “keeping up” in class. The teacher is becoming increasingly frustrated at Mandeep’s apparent lackadaisical attitude towards work. It is not uncommon for the rest of the class to be busy working on the assigned math exercise and for Mandeep to be sitting with her book unopened. She often seems forgetful and, while knowledgeable about subject areas covered prior to the injury, she seems to have a great deal of difficulty acquiring new information. The educator characterizes Mandeep’s behaviour as having lost her “get up and go.”
What is cueing?
A cue is any type of signal that is used to prompt another person to either engage or disengage in a particular behaviour. There are essentially four types of cues: direct and indirect verbal cues, direct and indirect nonverbal cues (see accompanying chart).
Verbal
Direct Verbal Cue:
The student is reminded verbally, explicitly and specifically as to what to do/what is expected (e.g., "Joey, please do question #5 of your homework now.").Indirect Verbal Cue:
The verbal cue is given as a nonspecific reference that something should be attempted, but the student is required to make the inferences and is not being told by others what to do (e.g., "Joey, the lesson is over, what can you do next?").Nonverbal
Direct Nonverbal Cue:
A gesture or nonverbal action is used to directly remind the student to complete a task (e.g., pointing to the student’s workbook and handing him/her a pencil.).Indirect Nonverbal Cue:
A look, gesture, or other body language that implies what is to be done but does not directly focus on the desired behaviour (e.g., the student watches other students and/or the teacher begin doing the homework immediately after a lesson.).Possible deficits that cueing can assist with:
The possible behaviours that cueing can assist with can be broken down into two categories: (a) cueing used as a reminder; (b) cueing used as redirection.
Cueing used as a reminder
Cueing can prompt/remind the student to participate in an activity and assist him/her to (successfully) complete a task demand, as in the following situations:
- Failure to Initiate - Student does not start tasks especially during unstructured time; s/he may appear “lazy.”
- Memory Problems - Student has difficulty remembering the names of teachers and/or students that s/he meets.
- Student has difficulty remembering class material or expectations from day-to-day.
- Student has problems remembering the layout of the school environment, making it difficult to navigate from class to class.
- Student forgets to follow through on plans made the previous day.
- Attentional Problems - Student does not stay on task for a reasonable amount of time.
- Student is easily distracted, especially in noisy, over-stimulating environments.
- Organizational Difficulties/Obstacles - Student does not follow steps needed to complete a task in the proper order; his/her work appears sloppy, messy, poorly laid out, is often unfinished/incomplete.
- Problem-Solving - Student has difficulty planning out the steps involved in a task or problem.
Cueing used as redirection
Cues can also prompt the student to engage in alternative activities or thoughts that are more appropriate given the setting and/or more productive by introducing a novel idea and/or distraction, as in the following situations:
- Perseveration - A student appears to be stuck on a single verbal thought or action, which they repeat and cannot move on from, often described as a “broken record,” or doing something s/he cannot “get over.”
- Agitation - Student demonstrates low tolerance for frustration and becomes agitated and emotional, even angry or inappropriate for the context.
- Over-Stimulation - When in crowded, noisy, visually stimulating, or highly demanding environments the student becomes more engaged by the stimulation (e.g., inattention to the task at hand and attentive to the source of stimulation) and may also appear confused, agitated, unproductive, and even verbally or physically abusive.
- Rigid/Inflexible Thinking - Student forms a particular (often linear) opinion about something and is unwilling or unable to discuss or understand any other contradicting opinion.
How to use cueing
Initially, cues can be used to clearly, specifically, and explicitly tell a student to do a particular a task—direct verbal cues. Over time they can become less directive in nature and eventually become synonymous with environmental cues (e.g., time of day, current context)— indirect nonverbal cues. This is accomplished by starting with the most direct kind of cue and progressing through the different types of cues until the student can generate the desired behaviour using the least directive cue. Using the least directive type of cue ensures the opportunity for learning, self-control, and empowerment.
Implementation of Cueing Strategies
Student consistently fails to begin work when requested.
Assume the student is lazy or noncompliant and provide negative consequences as a means to promote initiation.
Identify what specifically the student has problems initiating (e.g., finding page in text, gathering materials).
Depending on the assignment, use verbal prompts (and/or a list), visual reminders, or proximity to assist the student to begin work.
Student seems to learn concepts but is consistently unable to retrieve information at a later time.
Assume the student is not able to learn new information.
Assume that the student is not trying hard enough.
Continually increase the workload in order to have the student “catch up.”
Provide the student with an outline.
Describe events, activities, or associations that reinstate the original learning context (e.g., "Yesterday, after recess, we were working on our drawings for the concert ...").
5.8 - Changing the Antecedent
Case Study
Meaghan and Daley did everything together. Being twins allowed the girls opportunity to doubly enjoy the events of their lives.
Preschool was their first great adventure outside the nurturing environment of their home. It was at the preschool playground that Daley took a tumble off the climbing equipment. Returning to school, after a brief absence, Daley began to exhibit behaviour that alarmed her teacher. Her teacher began to notice that whenever Daley was asked to complete a task such as tidying up after art time, her response was extreme or she was often unresponsive. Initially, her teacher attempted to address this misbehaviour through providing consequences such as withdrawing free time. The use of such consequences resulted in a dramatic increase in Daley’s misbehaviour. Following discussions with Daley’s parents and colleagues at her school, Daley’s teacher decided to try a very different approach. Instead of applying a consequqence after the behaviour had occurred, care was taken to anticipate a behavioural response and prepare in advance for the outcome to be positive. For example, at art time, Daley’s materials were kept simple and laid out in an organized way. Prompts and warnings were given, prior to clean-up and plenty of time was given for the transition. The approach tried by Daley’s teacher resulted in a much calmer and productive day for both student and teacher.
The Antecedent-Based Approach
When working with students with ABI who display unwanted behaviours, it is possible that the behaviours are simply a result of the student being oppositional.
However, it is more likely that the unwanted behaviours are the result of some kind of organically based cognitive deficit. These students do not enjoy engaging in unwanted behaviours, however, because of their injury they can become overwhelmed, confused, and/or overstimulated. Without the proper coping strategies, acting out becomes their only way of communicating their needs and/or reacting to their discomfort.
Therefore, these unwanted behaviours need to be seen as a means of communication and when devising behavioural strategies for a student with ABI, it is important that the focus always be on what is driving the behaviour.
Traditionally, the following model has been used to devise behavioural strategies:
Something happens to elicit a behaviour (antecedent), the student reacts to the antecedent (behaviour), and a consequence is then given in an attempt to either encourage or divert the student from engaging in the (wanted or unwanted) behaviour again.
In this model, the focus is put on providing a consequence for the behaviour with the idea that the student will learn to associate: 1) unwanted behaviour with an unpleasant consequence and, therefore, not engage in the behaviour again, or, 2) wanted behaviour with a favourable outcome.
The problem with this type of “Consequence- Focused” approach with a student who has an ABI is that the student may no longer have the ability to learn from consequences for one or more of the following reasons:
- Damage to the ventral medial prefrontal cortex — Damage to this area results in the inability to connect feelings associated with rewards and punishments to stored memories of the learning events.
- Inhibition Impairment — An impulsive student is likely to act before thinking about past episodes that resulted in negative or positive consequences.
- Impaired Working Memory — Students with poor working memory may be unable to recognize or have the capacity to simultaneously process the similarities between the current context, past episodes, and current intentions.
- Impaired Initiation — A student with an organically based initiation problem may not engage in a behaviour dictated by past learning experience because of an inability to activate any effective behaviours.
Therefore, instead of using a consequence-focused approach, using an “Antecedent-Based Approach” is often much more effective with a student who has an ABI.
By identifying the antecedent and modifying the environment/situation accordingly, you decrease the chance that the person will engage in the behaviour.
Putting it into Practice - How to apply an Antecendent-Based Approach
Identify the Antecedent:
- Often people are quick to say that a person just acts out for no reason, however, there is always an antecedent; some are just easier to identify than others.
Antecedents could include:
- Environmental Factors — overstimulation, sensitivity to light, noise, colour, weather, etc.
- Internal Factors — hunger, thirst, pain, fatigue, past experiences, medication side effects, sensorial limitations (e.g., vision), etc.
- Cognitive Factors — misinterpretation of the literal message, context, nonverbal signal, etc.
Change the Antecedent:
- Always change, and preferably eliminate the “triggers” of unwanted behaviours and introduce/ promote those of wanted behaviours.
- Remember that it is always easier, and often more desirable, to change the environment than it is to change the person.
- And, when you can’t change the settings, then anticipate the outcome as a means to minimize the negative response and maximize the positive one.
Examples of How to Make These Changes
This strategy modifies behaviour by providing the student with physical assists that can aid the student.
Student’s Behaviour: When asked to sit down, Jimmy walks to the other side of the classroom.
Teacher’s Response: “Good idea, Jimmy, we will need a pencil. While you are over there can you please grab one so we can get this work done?”
Rationale: Instead of consequencing Jimmy, which could very well lead to him becoming even more oppositional, the teacher turns his negative behaviour (walking to the other side of the classroom) into a positive behaviour (since you are over there, grab a pencil).
Student’s Behaviour: Jimmy does not get a pencil, but does come over and sit down.
Teacher’s Response: Looking at the daily schedule, the teacher says, “Wow, Jimmy by the look of this, you have been busy today. I’m going to put this right in front of us so we can see all that you have accomplished. Let’s get your writing assignment done.”
Student’s Response: Jimmy picks up his pencil and begins to work.
Student’s Behaviour: Jimmy takes the schedule and places it in his book bag under his desk.
Teacher’s Response: "Putting your schedule away someplace safe is a good idea Jimmy, that way you will know where it is the next time you need it. Now let’s get to work."
Rationale: Instead of addressing the defiant behaviour (not leaving the schedule on the desk) and providing consequences to try and modify it, the teacher turns it into something positive (by putting it away you will know where it find it for next time).
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