In Individual Clinical Work (cont.)
In addition to information about the type and severity of aggression, the OAS-MNR also enables details about what was happening in the environment to be captured. This can then make a potentially valuable contribution to an operant conceptual framework for understanding neurobehavioural disability and a formulation regarding what is maintaining aggression (see the case study within the SASBA web pages for a detailed example as this scale captures identical environmental information to the OAS-MNR). Regarding LM, Figure 1 shows that aggressive behaviour increased in frequency and severity when expectations that he participate in rehabilitation were introduced in week 3. OAS-MNR data confirmed that the majority of aggression took place in formal rehabilitation sessions as a consequence of being given a verbal prompt by members of the clinical team to engage in activity. Most recordings took place in the morning. Aligning this information with LM’s time-table confirmed that the majority of his aggressive behaviour happened during his morning hygiene routine. OAS-MNR recordings confirmed that the principal means of managing this behaviour was to ignore or downplay it as much as possible (92%). Data supported an escape/avoidance formulation: previously, LM’s aggression had been reinforced by staff in previous rehabilitation settings by reducing their expectations of what was required of him, in order to reduce risk. Whilst understandable, this strategy was counter-productive to LM making progress in rehabilitation. As a consequence, NBIC clinicians continued to downplay LM’s aggression, carry on with tasks and maintain achievable expectations. A positive reinforcement programme to strengthen and encourage behaviour incompatible with aggression was also implemented.
Figure 1 confirms the success of this approach. The frequency of aggression, recorded using the OAS-MNR, shows a rapid decline from the 68 incidents recorded when expectations were increased in week 3. Data for severity of aggression shows an almost parallel response. Intrusiveness of intervention remains low throughout, confirming that in the majority of incidents it was possible for the clinical team to use the least invasive means of managing LM’s behaviour – downplaying aggression and maintaining task demands.
Follow-up data derived from OAS-MNR recordings at weeks 24 and 25 confirm that this programme was successful as no aggression was observed. Figure 1 also shows that these improvements took place after LM’s regime of sedating medication had been withdrawn.
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