Derek* is a 39 year old man who grew up in Liverpool with little parental support. As a young adult he started abusing alcohol and drugs and he has a long history of abuse. He never held a job and never had a stable family of his own. Derek was attacked in the street in 2002 and sustained a severe brain injury. As a consequence of that he has limited communication skills resulting in his inability to consistently convey his wants, wishes and basic needs, such as indicating pain. He can only use single words and gestures, and his severe dysarthria makes these single word utterances often unintelligible. His comprehension of language is also limited, sometimes no more than single words.
Derek is also irritable, potentially a pre-morbid personality feature exacerbated by the severe brain injury. He is short-tempered and easy to become agitated. Many times he will refuse to cooperate with staff attending his room, will ignore them or become visibly agitated. Derek is also a high dependency service user in terms of his nursing needs: He has a PEG feed for fluid replacement and medication, he is on a puréed diet due to dysphasia and choking risk, he has left-sided spastic haemiplegia, and is consequentially bed / wheelchair bound.
* Details have been changed to protect identity.
Based on observations from previous placements, ongoing feedback from York House floor staff and ABC analyses, we completed a functional behaviour analysis for Derek. Five factors were identified that serve as antecedents to aggression and other challenging behaviours.
What are the results of our interventions?
Within three months we witnessed a large reduction in all of Derek's challenging behaviours, as can be seen in the graph below (red indicates physical aggression, which was the most prevalent problem for Derek).
These changes mean interaction with Derek is much easier now, more people are willing to work with him, other service users are happy to interact with him, and he gets to enjoy many more social interactions than was previously possible for him.
Even more importantly, the reduction in all challenging behaviour allowed Derek to be engaged in quality of life related activities. The first encouraging sign of that was his ability to sit in a wheel chair for the first time in months. Once in his chair, he seemed happier and started indicating he would like to go outside. In a gradual manner we were able to support his request and allow him to go out into the community. The graphs below demonstrate that within three weeks at York House he was able to leave his bed and do so in an increasing manner (hours out of bedroom increased from nought to three hours per day after 12 weeks). Even more importantly, after four weeks we were able to take him outside the hospital (hours out of the hospital increased from 0 to 1.45 hours per day after 12 weeks). Derek now accesses the community on a regular basis, and this includes activities he chooses, such as pub visits, trips to buy himself DVDs or clothes, and milkshakes at McDonalds. This is a significant quality of life achievement for a man who was previously considered to be so challenging hardly anyone walked into his room!
What are our current plans for Derek?
We intend to help Derek increase his ability to control his life, despite his severe disability. The York House SLT works on a reliable communication paradigm, based on the Makaton method and the Talking Mats paradigm, so that Derek can indicate choices more consistently. We have made his room into a stimulating environment, with a large TV, a good stereo system and a selection of music and DVDs, all chosen by him. More importantly we attempt to use Smart House technology to increase his ability to control his environment, to be able to control the television, light, curtains in room and call for help.
Derek is a service user who will require long term support and whose behaviours will remain challenging. Therefore he will need on-going support within the neurobehavioural environment. However, staying within this environment has proven beneficial to him and made his life more meaningful.