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.

  1. Limited attention span and fatigue - Derek cannot tolerate extended environmental stimulation. In order to address that, all interventions were limited to 15 minutes in duration. A pacing programme was implemented, where following each intervention Derek is given a minimum of 30 minutes rest before the next intervention commenced.
  2. Pain and discomfort - In order to address that, Derek's pain relieving medication was administered 30 minutes prior to major daily care interventions. In this way, care was delivered at a time when his body was most protected from pain.
  3. Associational learning - Derek learned to associate entry into his room with care routines, which had unpleasant consequences: pain and discomfort, having his body exposed to strangers and being placed in a vulnerable position. Negative associational learning was manifested via screams and shrieks of horror as the carer entered the room and prior to any intervention. In order to extinguish this, frequent "pleasant" entries into the room were planned in conjunction with the required care entries. These included staff coming in to watch television with Derek, read magazines and more.
  4. Automatic behaviours - some of Derek's aggressive behaviour was the result of "Utilisation Behaviour", a concrete way of using objects in an automatic manner. For example, during meals, the way he holds his spoon can change the function of the spoon: when he holds it near the plate it is used as a feeding instrument and he will eat using it; when he raises it higher, it then becomes a dart and he will throw it. In order to address that, the staff member sitting with him gently kept Derek's hand position from reaching the high point where the spoon transformed into a dart. In consequence, the throwing of spoons during meal times has stopped, allowing him to eat in the company of others in the dining room.
  5. Trust - Derek is a high dependency person who requires others for all aspects of care. This impacts on his dignity and self-image as an adult, and can result in outbursts of aggression during care routines. In order to address this, he has a stable care team that he has learned to know and trust. In addition, short term contracts are used to build his trust. Thus, even when in discomfort, he knows how long this will last and that it will be terminated when promised. Simple measures such as talking to Derek throughout interventions and asking consent for everything that takes place has also helped to gain his trust in carers. In addition, all medical and hygiene plans include a dignity component, where his privacy is kept throughout the care routine.

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).

  • Total aggression reduced from 90 to 19.5 incidents per week.
  • Physical aggression reduced from 84 to 19.1 incidents per week.
  • Self harm reduced from 8.1 to 0.7 incidents per week.
  • Verbal aggression reduced from 6 to 0.4 incidents per week.
  • Unusual Behaviour reduced from 4.2 to 0.4 incidents per week.
  • Inappropriate sexual behaviour reduced from 0.6 to 0.1 incidents per week.

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!

Hours Out Of Hospital

Hours Out Of Bedroom

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.

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