applications of aba in pediatric medical rehabilitation...
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APPLICATIONS OF ABA IN PEDIATRIC MEDICAL
REHABILITATION SETTINGS Gregory Young, Ph.D., LABA, BCBA
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Increasing population: Improved prenatal medicine – more medically complex children are born Better neonatal and pediatric care – individuals are living longer
In many ways this is a new population
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Who are these children?
Children with… Cancer/Tumor Pre or post transplant/Organ failure Genetic/Chromosomal abnormalities Acquired or traumatic brain injuries Encephalitis
Strokes
Motor Vehicle Accident
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Who are these children?
Children with… Movement disorder (paralysis/palsy, MS, spasticity) Respiratory issues (tracheostomy, BiPAP/CPAP, or Ventilator support) Feeding/GI issues Sickle Cell Cystic Fibrosis (CF) Diabetes Intractable seizures Chronic Pain Multi-system medical anomalies
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS What is your experience with this population?
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Who are these children? Children that require ongoing medical care, often from multiple medical specialties Frequent hospitalizations Complicated medical regimens and medication schedules
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS There is no biological vacuum Many children have a number of physiological anomalies in addition to cognitive
impairments
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS These children are exposed to numerous hospitalizations and endure many painful and invasive medical procedures from birth.
Mechanical restraints (i.e., welcome sleeves) and chemical restraints (i.e., sedatives and anesthesia) are used frequently.
CHILDREN WITH CHRONIC COMPLEX MEDICAL CONDITIONS Medical trauma
Over generalized physiological arousal (classical conditioning)
Systematic and accidental reinforcement of aggressive and disruptive behaviors (operant conditioning)
MEDICAL REHABILITATION SETTINGS
Franciscan Children’s: Medical Rehabilitation
Kennedy Krieger Institute: Pediatric Rehabilitation Unit
MEDICAL REHABILITATION SETTINGS
Franciscan Children’s: Medical Rehabilitation
42 beds across two medical units
The largest dedicated pediatric rehabilitation center in New England
Service children as young as a couple months into early adulthood
Length of stay varies from 1 to 2 weeks up to 5 to 6 years
PSYCHOLOGY’S ROLE
Neuropsychological Testing (snap shot assessment)
Neurological Monitoring (progress monitoring)
Adjustment to medical condition/hospital stay
Coping with loss and end of life planning
Discharge preparation
PSYCHOLOGY’S ROLE
Preparation for medical procedures
Reducing problem behaviors Medical refusal Removal of medical equipment Self-stimulatory behaviors related to medical equipment Reducing impulsive behaviors
Increasing motivation and compliance with therapies
Monitoring behavioral problems
Evaluating preferences and responses to stimuli
Writing behavior plans
Teaching independence of medical care
Assisting in an individual’s relearning of activities of daily living
Parent and staff training
CASE STUDY 1: TOM
6 year old male
Has lived on the rehab unit for 5 years
Was born with lung disease and heart failure
Needs a heart and lung transplant
Was not expected to survive past 1 year
CASE STUDY 1: TOM
Requires 24 hour ventilator support
Improving medical stability
Non-ambulating
Non-verbal (signs “more” & “all done” and will point to the TV)
Significant cognitive impairment
CASE STUDY 1: TOM
Consult concern: Destroys trach and pulls trach off (self-decannulation)
Risk: could cause death
CASE STUDY 1: TOM
CASE STUDY 1: TOM
Step 1 Collect data
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B: Computerized Prompts
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CASE STUDY 1: TOM
Step 2 Determine function Access to attention
Access to water
Self-stimulatory
Step 3 Evaluate Interventions Reduce attention (low treatment adherence – ineffective)
Reinforce safe behavior (low treatment adherence – ineffective)
Aversive flavor (increased behavior)
Sensory Extinction
Abolishing operations
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Thickened Water (Fixed Interval 1 Hour)
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Increased to 25ml
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Noncontingent Access to 10ml Honey Thickened Water (Fixed Interval 1 Hour)
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Increased to 25ml
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Daily Frequency of New Trachs Required Baseline Deflated Cuff
Noncontingent Access to 10ml Honey Thickened Water (Fixed Interval 1 Hour)
Daily
Average Per Phase
Increased to 25ml
CASE STUDY 2: MAX
5 year old male
Rare genetic deletion – resulting in extremely low tone.
Severe obstructive sleep apnea (OSA) and recurrent aspiration pneumonia (9 hospitalization in the past year)
Diagnosed with autism - Highly verbal and impulsive
CASE STUDY 2: MAX
Reason for admission: CPAP desensitization
CPAP is an effective treatment in 86% of children with OSA
Poor compliance and adherence occurred in 92% of the cases with poor outcomes (Marcus, Davidson-Ward, Mallory, 1995)
Strategies based on the principles of Applied Behavior Analysis have been shown to be the most effective intervention (Koontz, Slifer, Cataldo, Marcus, 2003)
CASE STUDY 2: MAX
Treatment package components: Positive & Negative Reinforcement Graduated Exposure Response Prevention (Escape Extinction) Distraction Counter Conditioning Stimulus Fading Demand Fading (Thinning the schedule of reinforcement) Systematic Generalization
CASE STUDY 2: MAX
CASE STUDY 2: MAX
Step 1: Conduct sleep assessment Improve sleep hygiene Decrease sleep onset latency Decrease nighttime awakening
Step 2: Baseline tolerance of mask Trial one: 3 seconds on hand
Trial two and three: refusal to allow the mask to touch him
CASE STUDY 2: MAX
Step 3: Gain basic compliance (High P) Establish SR+ contingency (pretending to be racecars and running laps around play
room)
Step 4: High P (compliance task) Low P (mask on hand for 1 second) sequence with SR+
(more running)
CASE STUDY 2: MAX
Step 5: Demand fading (increase duration of mask on hand)
Step 6: Move mask: hand forearm elbow shoulder ear cheek nose/face
Step 7: Increase duration to 30 second
CASE STUDY 2: MAX
Step 8: Stimulus fading (adding each component of the CPAP)
Step 9: Shift away from running and generalize to bed
Step 10: Use overnight, FC for breaks, escape extinction
CASE STUDY 2: MAX
Notes: I ran miles Caregivers needed support during first extinction Consultation with medical (Pulmonary) team is essential Do not fade air pressure levels Do not connect the mask to the machine without the machine on Do not put a mask on a sleeping child By day 7 he was requesting the mask so that he could earn things Within a 15 day admission 3 years of battling was over
CASE STUDY 3: BEN
18 year old male with (at baseline): Cerebral Palsy (CP) Intellectual impairment Hearing Impairment Non-verbal (understood sign and could make some switch based choice) Non-ambulating
CASE STUDY 3: BEN
Ben experienced severe Baclofen withdrawal following a Baclofen pump replacement. Resulting in frequent dystonic episode (dystonic storming): spasticity, muscle
contraction, sweeting, elevated heart rate Not associated with a change in consciousness Very painful
CASE STUDY 3: BEN
Goals of consult: Low responsiveness preference assessment Data collection
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ArmWrestling
Water onFace
Vanilla(Smell)
Hand inWater
Football Movie "Up" Massage Bubble Party In theUSA
Talking
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Preference Assessment Responses
Positive
Neutral
Negative
CASE STUDY 3: BEN
Identified stimuli Arm Wrestling
Water on Face
Vanilla (Smell)
Hand in Water
Ben’s day was imbedded with NCR using these stimuli
Additionally these stimuli were evaluated as environmental strategies to decrease the
length of dystonic episodes. ¾ of observed trials, there was a correlation between the use of these strategies and the end
of the episode
CASE STUDY 3: BEN
Data collection Very difficult to judge effect of treatment Variable rates of the behavior Emotionally distressing to watch the behavior
90 min episode and 60 min episode both feel equally as miserable Agitation: Any combination of two of the following: heart rate above 130,
grinding teeth, one of his legs being elevated by his own effort, negative or distressed vocalizations or moaning, significant contractions of arms, significant shaking of body, and/or sweeting. Momentary time sample once per hour
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io o
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Agitation Baseline Dantrolene Rampt to 100mg
Dantrolene 50m
g
No D
antrolene
Risperdal .5mg
Risperdal 1.0mg
CASE STUDY 4: JEN
12 year old girl Admission due to a sudden stroke while walking down the stairs at home Previous healthy high achieving child Home schooled by mom
Current presentation: Non-verbal, non-ambulating, responsive to environmental stimuli,
and seemed to have good receptive language
CASE STUDY 4: JEN
Reason for consult: Motivation during therapies. Therapy was hard and painful and she would refuse to comply to demands. Conducted intake with mom
Identified horses as her highest preferred topic
Observed several therapy sessions
Hypothesized escape was the functions
Created a horse based token system with
brakes from therapy as the backup reinforcer
CASE STUDY 4: JEN
Conducted a co-treat with PT While in the stander, the patient was asked to make specific motor movement Patient complied and earned her first token Patient wanted to continue to look at the rest of the horse pictures but was prompted back to her work and the pictures were removed Patient became upset and started to cry Mom got upset and asked me to leave
CASE STUDY 4: JEN
This case represents the greatest clinical mistake I have ever made (that I know about). What did I do wrong? I did not develop a strong enough relationship with the mother or patient I did not consider the emotionality of this case I was too rigid I did not consider/trust the mother’s role as her teacher
CONCLUSION
Research in adult psychotherapy has shown that the strength of the therapeutic relationship is the greatest predictor of positive outcomes Better predictor than therapeutic modality What matters in life is forming meaningful relationships What matters in our work is forming meaningful relationships
QUESTIONS