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Developing a Behavior Modification Program

    It is almost never ideal for a family member to act as a therapist or behavior modifier.  However, there are situations in which it might be helpful for all members of the family to understand the principles underlying a behavior-management program. 
    Management programs can apply to all levels of head injured patients.   You may think your loved one will be offended by what appears to be a child-oriented approach.  Is is true that the procedures resemble techniques used with children with behavior problems.  However, you can remind your loved one that life is based on contracts, and this is what is being set up - a behavior contract.   If he can understand that this is necessary for him to get through the real world, he should be more agreeable to follow through. 

What are the problem areas?
   
To take an organized approach to behavioral change, you must first determine what areas you want to address.  Start by making a comprehensive list of all the problems.  Divide this list into "Things I want him to do" and "Things I want him to stop doing"

Where should we begin?
   
You might start by choosing five areas that have been deemed absolutely necessary to change.  You will need to collect baseline data so you can obtain objective information regarding the rate and intensity.  Collecting the data requires that you count the number of times a particular behavior occurs. 
    Examples are described in the following charts.  Click to enlarge:

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Who should carry out the program?
   
It is most practical for the person who has the greatest contact with the head injured individual to monitor the program.  You must be sure the person doing the recording is willing to stick to the plan and enforce the program.  It is very important to carry through with whatever consequences have been set up. 

What basic principles do we need to know?
   
Very difficult or severe behavior problems will require professional intervention.  If you experience difficulty learning or applying these principles, you should consult a mental health professional.  It will take time to set up a program which works best for your loved one.  It is best to begin with just one behavior.  This will help you from becoming overwhelmed.  The following terms are some that you will need to know and be able to apply to your family member:

    Consequences.  Consequences are defined as events that follow a behavior and either strengthen or weaken that behavior.  Consequences that follow a behavior and result in an increase or strengthening of that behavior are called reinforcers.  Consequences that follow a behavior and cause that behavior to decrease or weaken are called punishers.
      
Consequences that increase or strengthen behavior include:

  1. Paycheck - a paycheck is a consequence that strengthens the behavior of going to work each day.

  2. Positive comments/compliments - Each time 12 year old Chris washes the dishes, his mother says "Chris, you did a great job!"  This comment strengthens the likelihood that Chris will repeat the behavior of washing the dishes in the future.

        Consequences that decrease or weaken behavior include:

  1. Traffic tickets - Receiving a ticket for speeding should decrease or weaken the behavior of driving too fast.

  2. Missing a doctor's appointment - each time you miss an appointment and do not call, you are charged for a visit.  The behavior of not calling is decreased.

Positive Reinforcement

Events or consequences that increase or strengthen a desired behavior are referred to as positive reinforcers.  Any behavior that is followed by reinforcing events is likely to reoccur.  Positive reinforcement (reinforcing events) can strengthen both desired (appropriate) and undesired (inappropriate) behavior.  The following are examples:

  1. Linda had difficulty controlling her inappropriate language.  Each time she cursed, either parent would respond by snickering, smiling, or touching her shoulder and saying, "Linda, you should not talk that way."  It was noted that her inappropriate language would increase in frequency.  The increase in behavior was due to the manner in which her parents responded to the swearing.  They looked astounded and surprised.  This gave Linda the attention she was seeking.  

  2. Joe's parents wanted to continue a cognitive rehab. program at home.   Joe frequently threw tantrums during these attempts.  His parents divided the two hour cognitive rehab. program into eight 15-minute sections.  Each time Joe cooperated for a 15 minute period of time, he was rewarded with a poker chip.  At the end of the day, Joe could exchange these chips for a trip to the mall, time watching TV, renting a video, or other activities he enjoyed.  Joe's time on cognitive tasks increased significantly through the use of positive reinforcement.

    Types of reinforcers

  1. Primary or unlearned reinforcers - are things which include food, drinks, toys and pleasurable activities.  They are unlearned because they are naturally pleasurable.

  2. Secondary or learned reinforcers - include such things as tokens, money, stars on a paper, grades.  A child learns when he brings home good grades, he receives a primary reinforcer such as a toy or ice cream.  

Punishment  Punishment is not the best process for altering behavior.  When the use of punishment is necessary, punishment should be administered immediately after the inappropriate behavior.  You should always provide a warning so the family member understands the consequences.  In addition, you should always be consistent and never threaten to punish without following through.
    The most effective punishment is the removal of a positive reinforcer.In the example above, this would be accomplished by taking back tokens from Joe for hitting his brother.  Because Joe wants the tokens, he will be less likely to hit his brother.

How do we set up the Behavior Program?

If your loved one has been participating in an inpatient behavior modification program, ask the therapist to modify it for home.  If this is not the case, you can follow the following steps:

  1. Put priorities on the behaviors you want to change.

  2. Initially, address only one or two behaviors.

  3. Collect baseline data with which you will be able to know if you are making progress.

  4. Determine the reinforcers.  Use primary or unlearned reinforcers at first, and then graduate to tokens or points that can be traded for primary reinforcers.

  5. Maintain a chart so that everyone can see exactly what is going on - both you and the head-injured loved one.

  6. Be consistent and follow through with the plan.  If the behavior is not reinforced each time, learning will be very slow.

  7. Make sure that you deliver the reinforcement immediately after the desired behavior.  Also, make sure that the family member understands the connection between his behavior and the reinforcement.

  8. Learn to recognize the signs that indicate you need to modify the program.  You may need to increase the amount of reinforcement to obtain a change.   You may need to add a  different reinforcer if the head injured person does not appear motivated to receive this particular reward.