Aaron was a college sophomore when he sustained a traumatic brain injury (TBI) during a motor vehicle accident. Prior to the accident Aaron was very involved in athletics and worked out on a regular basis. He attended college classes and was living independently at the time of the accident. Physically, Aaron did very well after the accident but was left dealing with some severe cognitive limitations and executive dysfunction. His family moved him to a group home following his rehabilitation.
Not long after moving into the group home the staff began complaining about many of Aaron’s behaviors. Aaron was not motivated to complete his personal hygiene routine or take care of his room to the staff’s satisfaction. Common complaints were that he listened to his music too loudly, did not shower or brush his teeth, would not do laundry and did not make his bed. The complaint that seemed to alarm the staff the most, however, was that he consistently made inappropriate sexual comments to the female staff working with him. Aaron wanted a girlfriend and would approach any female around him and strike up a conversation. This was problematic not only due to content of what was being said but that it interfered with public outings in that he showed great disinhibition with others.
Problems with Punishment
An example of this consequence-based plan follows: if Aaron does not make his bed, he cannot go on the outing” or “if he says something inappropriate to a female staff member, he loses his personal, private-TV privileges for a few hours ”. There are two things written on the bottom of the plan: 1) For Aaron to be treated as an adult, he must act like one, and 2) If Aaron does not comply with staff request after one reminder, don’t argue with him but do remind the staff on the next shift so the punishment could be completed. In this plan there was a chance that he could do something “wrong” on Tuesday and not get “punished ” for it until Wednesday.
This plan was destined to fail for numerous reasons, the most important of which was that Aaron was not part of creating the plan. The punishments were so unrelated to the behavior they meant nothing to Aaron. For example, losing the privilege of listening to music on the stereo is not a realistic consequence for refusing to brush your teeth. The comments listed for staff at the bottom of his plan set a negative tone of interaction between staff and consumer and in some instances, were demeaning to Aaron. The last comment on the plan could set up a cycle of conflict by “ carrying over” a consequence to the next day. Let’s say Aaron did not brush his teeth when he went to bed on Tuesday night but did brush them first thing on Wednesday morning upon waking up. Even though he was compliant on Wednesday, the staff was to “carry over” the punishment from Tuesday night. In that situation, he was given no reinforcement for brushing on Wednesday. These plans create an unnecessarily negative situation on an almost daily basis. When Aaron did comply, it was imperative that he be reinforced in order for that behavior to occur again. This plan had no mechanisms to reinforce desired behavior; it only punished negative behaviors. Plans that use punishment only establish very negative interactions between staff/caregivers and consumer. Taking away items that belong to the individuals also create extreme power struggles. Few people would react positively if someone came to their home and said, “You didn’t work hard enough yesterday, we’re taking your TV for a few days. We’ll give it back when we think you are ready.”
Making Environmental Modifications and Teaching Replacement Behaviors
Some of the previous facility’s staff concerns were easily remedied. The new facility bought him a set of headphones for his stereo and eliminated the entire music volume issue without the need for a behavior plan. Through talking with Aaron, it was discovered that he always worked out in the morning and did all of his personal hygiene routines at the gym. The staff purchased a membership to the YMCA and following his workout, he would shower, brush his teeth and comb his hair with no prompting. What the first facility failed to see was the fact that Aaron’s desire for a girl friend could have been used as a motivator to increase appropriate behaviors. When the staff talked with him about wanting a girlfriend, they discussed that fact that being clean with clean clothes would be more appealing to women. The most problematic issue for Aaron was his desire for a girlfriend and his somewhat offensive manner in relaying this desire. The staff and Aaron sat down and developed a plan. The girls gave him very specific feedback about why they thought what he said was offensive and how undesirable he would be as a date. They taught him replacement behaviors/comments for things in order to better communicate with females his age. He decided a place to meet girls his age was Old Navy stores. With a staff person with him, they would go to the store. Prior to going they discussed not talking with girls that had rings on their left hand or girls that appeared to be with a parent. This was explained by telling Aaron that girls with rings on their left hand might be married and girls with a parent might be too young. They helped him rehearse lines like, “could you help me find a large T-shirt” to break the ice. The staff were always close by but not right next to him and if they felt things were going badly they would simply walk up and say it was time to go. A very important thing to remember about behavior change is that it is not helpful to just eliminate an undesired behavior without teaching the individual a more appropriate replacement behavior. Aaron just wanted to talk to girls his age but needed some tools to actually use that skill.