Brian's Example

Brian was 9 years old when he was involved in a motor vehicle/pedestrian accident. He was an energetic, healthy young boy who had always been extremely bright and inquisitive. Following the accident, Brian was in a coma for 9 months. When he came out of the coma, he received rehabilitative therapies and returned to school. At age 16, he was still in school and needed all related services for support. He also experienced significant cognitive difficulties. Because of his age, the school was actively trying to place him on a supervised job-site for possible future employment. One of the many difficulties with a job-training situation was Brian’s lack of personal insight. Even though he had severe cognitive and physical limitations, he still saw himself as the same person he had been prior to the accident. If he was given a task that he considered beneath his skill level, he would become aggressive.

Brian was placed on a cafeteria job-site stocking the drink cooler. As a control. This made placing the drinks in rows a very difficult task. He also showed decreased attention to task and would become lost or bored during an activity and forget or lose interest in what he was doing. When Brian had down time, he would become physically and verbally aggressive and extremely noncompliant. On numerous occasions, he had to be physically removed from the worksite because of aggression toward the staff.

After several work site complications, an assessment was done to determine if the cause of the aggression was interaction with staff, the actual work task, Brian’s physical limitations or the environment in which he had been placed. Behavioral data, direct teacher observation and staff/family interviews were used to collect data for this assessment. Through data collection and direct observation, it was determined that Brian needed much more positive verbal interaction to stay engaged in the activity. Involving Brian in the assessment process gave the staff valuable insight regarding his actual needs. Of the various components considered in the assessment, it was determined that the staff member coaching Brian was critical for the success of the task. The staff members he chose most often were very outgoing and used lots of humor when working with him. Humor used by a staff member was very influential for keeping him engaged in his activity and reducing aggression. He was placed on a reinforcement schedule that relied only on verbal praise from staff. This praise was initially given at 5 minute intervals. On this plan, his aggression frequency dropped to one time every two weeks from the original one to two times daily as recorded in previous data collections prior to intervention. By using the data collected, it was also determined that too many people in the cafeteria during Brian’s work time would also lead to heightened aggression. His time to stock the cooler was changed to a time when he was in the area alone with a staff member. By adding verbal praise at 5-minute intervals and reducing the number of individuals in the work area, instances of aggression dropped to zero in an 8 week period. The cafeteria staff was no longer afraid of Brian and would interact with him. The interactions served as another form of reinforcement for him.