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Featured open access content

Comprehending Aggressive Behavior Following A Brain Injury: An Explanatory Framework For Neurobehavior
Jeff Kupfer, PhD, Peter R. Killeen, PhD, & Randall D. Buzan, MD

Content currently available in print only
Antecedent Interventions and the Management of Behavioral Dysregulation
Ron Allen, PhD, BCBA, CBIS and Tom Hall, MA, CBIS-T

Acceptance Commitment Therapy: The Time to ACT Is Now
Dixie Eastridge, MA, BCBA, CBIS

 Differential Reinforcement of Alternative Behavior in the Social Networking Website Facebook
Zach Maple, MA, LPC, BCBA and Leigh Schrimpf, MS, BCBA

Tutorial for Creating Cumulative Graphs in MS Excel 2007
Leigh Schrimpf, MS, BCBA

Message from the Guest Editor

 

Jeff Kupfer, PhD and Randall D. Buzan, MD

Behavior analytic approaches have been widely used to treat persons with brain injuries since the 1980’s, kicked off a decade earlier by the remarkable research of Murray Sidman. Sidman developed early technology for patients with aphasia leading to the discovery and analysis of emergent stimulus classes and equivalent relations (Sidman, Stoddard, Mohr, & Leicester, 1971). Sidman (1994) reflected:

 Since many of the patients could not speak or write intelligibly, we had to devise ways to investigate their language comprehension without requiring them to speak or write. To this end, we adapted the matching-to-sample procedure, which was originally developed to study the behavior of nonhumans. Using this procedure, we were able to evaluate how well the patients could relate text, objects, and pictures to words that they heard, saw, or touched.

Sidman’s research was groundbreaking in the area of conditional discrimination and contextual control of behavior, but Applied Behavior Analysis (ABA) ultimately became the preferred approach in neurobehavior treatment, addressing severe agitated behaviors via environmental modification.

The scope of ABA is broad and its impact on brain injury treatment is reflected in the growing research literature. On the website of the Cambridge Center for Behavioral Studies (www.behavior.org), for example, a bibliography lists over 100 articles related to ABA treatments for persons with brain injury. Interestingly, more research articles relate to teaching and skill acquisition than to reducing challenging behavior – belying ABA’s more frequent association with behavior management strategies. (Parenthetically, complete reprints of Sidman’s early research on aphasia can be found on this same website.)

In spite of a robust literature on the subject, skill acquisition treatment in TBI is still underutilized. This may devolve from the fact that most of the teaching and skill acquisition research is published in ABA related journals rather than rehabilitation or brain injury journals. In addition, some still consider ABA a “collection of techniques” to be used in limited situations (e.g., behavioral dysregulation), not appreciating its larger utility in the rehabilitation process.

The roles of consequences and contexts in the regulation of behavior have received considerable attention in behavior analysis and have great applicability in the treatment of TBI. This edition of Brain Injury Professionalshowcases articles on conceptual issues about behavior and brain injury that we hope will stimulate discussion and expand the scope of neurobehavior rehabilitation.

We start with an examination of the historical perspective of “causes of behavior”, pointing out that materialistic accounts of behavior following brain injury, although important, comprise only a portion of a complete explanation for behavior (Kupfer, Killeen, and Buzan). The authors argue that a more complete explanation should include an examination of triggers, functions, and formal models used to talk about these various causes of behavior.

Allen and Hall then review antecedent interventions in treating persons with brain injury and suggest that an understanding of the role of the limbic system is critical for understanding the contexts of antecedent events and consequences.

Eastridge provides an introduction to Acceptance Commitment Therapy (ACT) by tracing its origins to behavior therapy and cognitive behavior therapy. ACT paves the way to integrating mindfulness approaches to treating persons with brain injury within a functional contextualism model.

Of course no special edition of a publication featuring behavior analysis would be complete without at least one single-subject design experiment. Maple and Schrimpf provide an example of how the effects of responses by “followers” in social media may contribute to shaping appropriate and inappropriate “posts” by a young man with brain injury. This study uses cumulative graphing techniques to describe the daily changes in posting activities as variables are systematically introduced.

Cumulative graphing has been used in ABA to show the effects of treatment variables and other important events that may influence responding. Schrimpf provides a brief tutorial on how to develop cumulative graphs using Excel spreadsheets which can be edited and used in a variety of ways to describe long term treatment effects in neurobehavioral rehabilitation.

Finally, Mozzoni provides an excellent book review of Susan Schneider’s The Science of Consequences which examines the role of conspicuous and inconspicuous environmental consequences and how they influence genetic predispositions, “genes x environment” interactions, and the effect on the brain and body.

We hope you enjoy this collection of articles that may enrich your work with TBI patients.

References:

Sidman, M. Equivalence relations and behavior: A research story. Boston, MA: Authors Cooperative, Inc, 1994.

Sidman, M., Stoddard, L.T., Mohr, J.P., Leicester, J. Behavioral studies of aphasia: Methods of investigation and analysis. Neuropsychologia 1971; 9:119-140.

about the guest editors: 

Jeff Kupfer, PhD received his doctoral degree in psychology from the University of Florida, specializing in the experimental analysis of behavior. He has conducted research in animal models of complex learning and psychopathology, as well as research examining environmental influences on bipedal travel in persons with visual loss. Jeff is a licensed psychologist in Massachusetts, Colorado, and Nebraska, a doctoral-level Board Certified Behavior Analyst, and a lecturer at the University of Colorado-Denver. He was the first president of the Four Corners Association for Behavior Analysis, and is a founder and Trustee for the Cambridge Center for Behavioral Studies. Jeff has been practicing behavior analysis since 1984 specializing in the treatment of severe behavioral disorders in persons with brain injury, developmental disabilities, mental illness, and other neurologically-based disorders. He has published in the areas of behavior analysis, pharmacology, and visual impairments, and has served as a guest reviewer for professional journals. Jeff is a consultant for Imagine Behavioral Health Services and Learning Services Neurobehavioral Institute – West in Colorado.

Randall Buzan, MD graduated summa cum laude from the University of Michigan with a BS in Psychology, Alpha Omega Alpha from U-M Medical School, and completed his psychiatry residency at the University of Colorado and analytic training at the Denver Institute. He completed a fellowship in psychopharmacology at the University of Colorado and another mini-fellowship in electroconvulsive therapy at Duke. He joined the psychiatry faculty at the medical school and did psychopharmacology and neuropsychiatry research for 9 years. Randy served as a peer reviewer for the Journal of Neuropsychiatry, is a Distinguished Fellow of the American Psychiatric Association, and has published 25 papers and book chapters and presented nationally on treatment of brain injury and developmental disabilities. Randy consulted for 24 years at two Colorado’s Regional Centers for ID individuals, and continues to consult at Craig Hospital and Learning Services on TBI and spinal cord injury.

To get full access to the edition or to all of the editions, please click here to join North American Brain Injury Society (NABIS)

Featured open access content
Comprehending Aggressive Behavior Following A Brain Injury: An Explanatory Framework For Neurobehavior
Jeff Kupfer, PhD, Peter R. Killeen, PhD, & Randall D. Buzan, MD

Content currently available in print only
Antecedent Interventions and the Management of Behavioral Dysregulation
Ron Allen, PhD, BCBA, CBIS and Tom Hall, MA, CBIS-T

Acceptance Commitment Therapy: The Time to ACT Is Now
Dixie Eastridge, MA, BCBA, CBIS

 Differential Reinforcement of Alternative Behavior in the Social Networking Website Facebook
Zach Maple, MA, LPC, BCBA and Leigh Schrimpf, MS, BCBA

Tutorial for Creating Cumulative Graphs in MS Excel 2007
Leigh Schrimpf, MS, BCBA

Message from the Guest Editor

Jeff Kupfer, PhD and Randall D. Buzan, MD

Behavior analytic approaches have been widely used to treat persons with brain injuries since the 1980’s, kicked off a decade earlier by the remarkable research of Murray Sidman. Sidman developed early technology for patients with aphasia leading to the discovery and analysis of emergent stimulus classes and equivalent relations (Sidman, Stoddard, Mohr, & Leicester, 1971). Sidman (1994) reflected:

 Since many of the patients could not speak or write intelligibly, we had to devise ways to investigate their language comprehension without requiring them to speak or write. To this end, we adapted the matching-to-sample procedure, which was originally developed to study the behavior of nonhumans. Using this procedure, we were able to evaluate how well the patients could relate text, objects, and pictures to words that they heard, saw, or touched.

Sidman’s research was groundbreaking in the area of conditional discrimination and contextual control of behavior, but Applied Behavior Analysis (ABA) ultimately became the preferred approach in neurobehavior treatment, addressing severe agitated behaviors via environmental modification.

The scope of ABA is broad and its impact on brain injury treatment is reflected in the growing research literature. On the website of the Cambridge Center for Behavioral Studies (www.behavior.org), for example, a bibliography lists over 100 articles related to ABA treatments for persons with brain injury. Interestingly, more research articles relate to teaching and skill acquisition than to reducing challenging behavior – belying ABA’s more frequent association with behavior management strategies. (Parenthetically, complete reprints of Sidman’s early research on aphasia can be found on this same website.)

In spite of a robust literature on the subject, skill acquisition treatment in TBI is still underutilized. This may devolve from the fact that most of the teaching and skill acquisition research is published in ABA related journals rather than rehabilitation or brain injury journals. In addition, some still consider ABA a “collection of techniques” to be used in limited situations (e.g., behavioral dysregulation), not appreciating its larger utility in the rehabilitation process.

The roles of consequences and contexts in the regulation of behavior have received considerable attention in behavior analysis and have great applicability in the treatment of TBI. This edition of Brain Injury Professional showcases articles on conceptual issues about behavior and brain injury that we hope will stimulate discussion and expand the scope of neurobehavior rehabilitation.

We start with an examination of the historical perspective of “causes of behavior”, pointing out that materialistic accounts of behavior following brain injury, although important, comprise only a portion of a complete explanation for behavior (Kupfer, Killeen, and Buzan). The authors argue that a more complete explanation should include an examination of triggers, functions, and formal models used to talk about these various causes of behavior.

Allen and Hall then review antecedent interventions in treating persons with brain injury and suggest that an understanding of the role of the limbic system is critical for understanding the contexts of antecedent events and consequences.

Eastridge provides an introduction to Acceptance Commitment Therapy (ACT) by tracing its origins to behavior therapy and cognitive behavior therapy. ACT paves the way to integrating mindfulness approaches to treating persons with brain injury within a functional contextualism model.

Of course no special edition of a publication featuring behavior analysis would be complete without at least one single-subject design experiment. Maple and Schrimpf provide an example of how the effects of responses by “followers” in social media may contribute to shaping appropriate and inappropriate “posts” by a young man with brain injury. This study uses cumulative graphing techniques to describe the daily changes in posting activities as variables are systematically introduced.

Cumulative graphing has been used in ABA to show the effects of treatment variables and other important events that may influence responding. Schrimpf provides a brief tutorial on how to develop cumulative graphs using Excel spreadsheets which can be edited and used in a variety of ways to describe long term treatment effects in neurobehavioral rehabilitation.

Finally, Mozzoni provides an excellent book review of Susan Schneider’s The Science of Consequences which examines the role of conspicuous and inconspicuous environmental consequences and how they influence genetic predispositions, “genes x environment” interactions, and the effect on the brain and body.

We hope you enjoy this collection of articles that may enrich your work with TBI patients.

References:

Sidman, M. Equivalence relations and behavior: A research story. Boston, MA: Authors Cooperative, Inc, 1994.

Sidman, M., Stoddard, L.T., Mohr, J.P., Leicester, J. Behavioral studies of aphasia: Methods of investigation and analysis. Neuropsychologia 1971; 9:119-140.

about the guest editors: 

Jeff Kupfer, PhD received his doctoral degree in psychology from the University of Florida, specializing in the experimental analysis of behavior. He has conducted research in animal models of complex learning and psychopathology, as well as research examining environmental influences on bipedal travel in persons with visual loss. Jeff is a licensed psychologist in Massachusetts, Colorado, and Nebraska, a doctoral-level Board Certified Behavior Analyst, and a lecturer at the University of Colorado-Denver. He was the first president of the Four Corners Association for Behavior Analysis, and is a founder and Trustee for the Cambridge Center for Behavioral Studies. Jeff has been practicing behavior analysis since 1984 specializing in the treatment of severe behavioral disorders in persons with brain injury, developmental disabilities, mental illness, and other neurologically-based disorders. He has published in the areas of behavior analysis, pharmacology, and visual impairments, and has served as a guest reviewer for professional journals. Jeff is a consultant for Imagine Behavioral Health Services and Learning Services Neurobehavioral Institute – West in Colorado.

Randall Buzan, MD graduated summa cum laude from the University of Michigan with a BS in Psychology, Alpha Omega Alpha from U-M Medical School, and completed his psychiatry residency at the University of Colorado and analytic training at the Denver Institute. He completed a fellowship in psychopharmacology at the University of Colorado and another mini-fellowship in electroconvulsive therapy at Duke. He joined the psychiatry faculty at the medical school and did psychopharmacology and neuropsychiatry research for 9 years. Randy served as a peer reviewer for the Journal of Neuropsychiatry, is a Distinguished Fellow of the American Psychiatric Association, and has published 25 papers and book chapters and presented nationally on treatment of brain injury and developmental disabilities. Randy consulted for 24 years at two Colorado’s Regional Centers for ID individuals, and continues to consult at Craig Hospital and Learning Services on TBI and spinal cord injury.

To get full access to the edition or to all of the editions, please click here to join North American Brain Injury Society (NABIS)

 

By Michael E. Porter and Elizabeth Olmsted Teisberg

506 pp. Boston,

Harvard Business School Press, 2006

The US healthcare system is tremendously complex in magnitude  with delivery models fraught with high costs and variable outcomes.  Under the current  system of incentives, costs continue to escalate due to variation in care, and fragmentation of services. Many patients living with complex conditions are faced with  an immensely intricate system and, at the end of the day, unmet needs.

With incredible knowledge of business strategy and competition, the authors have studied health care models and systems in the US and in other countries. In Redefining Health Care, they provide a detailed assessment of the misalignment of incentives and the ill placement  of competition. Central to ills of the current model of US healthcare are  reimbursement models based on fee-for-service, with medical culture designed to provide “more”  services instead of focus on “value”.  The orientation to shift costs to other stakeholders instead of true coordination and share-decision making results in higher costs and low value.  Without a major shift in how health care systems are designed (or re-designed), with integration and focus on delivery of quality and effectiveness (i.e. getting more of the healthcare dollars spent), the authors argue credibly that the system will become unsustainable. At risk is the quality of care for all Americans.

This is one of the most important readings that has shaped my thinking about healthcare.  I find the multiple specific examples in a variety of healthcare settings (in the US and abroad) and operational creativity illustrated in this book highly useful.  The recurring emphasis on value creation with functional outcomes and quality of life metrics, is more recognized and incorporated into other outcome metrics by specialties outside of the rehabilitation specialties.

Some of the encouraging signs from the implementation of the Affordable Care Act have resulted in increased number of covered lives and decreased spending on healthcare.

Although published nearly a decade ago, the thoughtful critique and guidance for transformative change to move health care toward a healthy model of competition is crucial and relevant. Some of the most important remedies described in this book are incorporated into Accountable Care Organizations and Patient-Centered Medical Home models.  This important publication is immensely worthy of study and discussion by all healthcare participants.

About the reviewer

Dr. Benton Giap is health care executive with over 15 years of experience in clinical care and physician leadership with various organizations, including The Permanente Medical Group (TPMG) and Spaulding/Massachusetts General Physician Group (MGPO).  He was a former Chair of the Department of Physical Medicine and Rehabilitation at Santa Clara Valley Medical Center in San Jose, CA. He is currently a Medical Director for Anthem Blue Cross Commercial line of business. He is a member of AAPMR Work Group for Innovative Payment and Practice Models (IPPM) with the purpose of identifying and promoting innovative payment and practice models for the specialty of PM&R.

Dr. Giap completed his medical education at the University of Texas, and he trained in Houston at Baylor College of Medicine/The Institute for Rehabilitation and Research. He completed a Brain Injury Fellowship at Wayne State University/Rehabilitation Institute of Michigan and a Master in Business Administration at UCLA/Anderson School of Management.

Featured open access content

Current Theories of Post-Traumatic Tinnitus
MIKHAYLO SZCZUPAK, MD, MICHAEL E. HOFFER, MD, FACS

Content currently available in print only
Neurotologic Evaluation of Posttraumatic Tinnitus
BRITTANY WEBER, MD AND BARRY STRASNICK, MD

Non-Otological Causes of Tinnitus
NATHAN D. ZASLER, MD, FAAPM&R, FAADEP, DAAPM, CBIST AND SARA ETHEREDGE, PT, DPT, CKTP, CCI, CMTPT

Sound Therapy Approaches: Post-Traumatic Tinnitus
MARC FAGELSON, PhD

Drug Treatments for Tinnitus: What’s New?
JINSHENG ZHANG AND EDWARD PACE

Alternative Medical Management Of Tinnitus
SYED F. AHSAN MD FACS, MICHAEL D. SEIDMAN MD FACS

 

Message from the Guest Editor

Guest Editor:  Nathan Zasler, MD

It was with some trepidation, as well as anticipation, that I accepted the offer to edit this issue of Brain Injury Professional on the topic of post-traumatic tinnitus. Tinnitus is a very common post-traumatic complaint; yet, unfortunately, there is a significant lack of understanding of this post-traumatic symptom and its myriad causes. Just as significantly, patients are often told that they just need to “live with it” and are not provided any treatment recommendations, when in fact depending on the etiology of the tinnitus, it might be quite treatable whether from a curative or modulation standpoint.
In putting this issue of BIP together, I have tried to take a holistic approach to tinnitus assessment and management. Every effort was made to provide the latest information on the topic by bringing together some of the top clinicians involved in tinnitus work in neuro-otology and audiology.

This issue of BIP has the articles organized in a logical order of progression to facilitate the learning process for readers. The first article by Dr. Hoffer et al focuses on causes of post-traumatic tinnitus and specifically the underlying pathoetiology of this symptom following TBI, head trauma and whiplash injury. The next article by Dr. Strasnick et al details the neuro-otological evaluation of tinnitus and provides readers with details regarding specific bedside assessment techniques and neurodiagnostic testing for this sensory complaint in post-trauma patients. The article by Dr. Zasler delineates other causes of tinnitus, both traumatic and non-traumatic, that may not seem necessarily obvious but should be considered in the context of the differential diagnostic work-up of such complaints with the emphasis being on non-otological causes of this sensory symptom. Dr. Fagelson has authored an excellent article providing an extensive review of current approaches to sound therapy for tinnitus management. Dr. Zhang’s article provides insights on historical and current research on potential drug treatment approaches for tinnitus modulation; whereas, Drs. Ahasan and Seidman’s article reviews alternative treatment approaches, both pharmacological and non-pharmacological, for tinnitus management. The second to the last article provides readers with a patient perspective through an interview on dealing with post-traumatic tinnitus following a traumatic brain injury. Lastly, Mr. Morris of American Tinnitus Association (ATA) reviews the goals of the organization and how it can be a resource to both professionals and the lay public alike on the topic of tinnitus.

It is hoped that this special issue of the Brain Injury Professional will enlighten readers on the topic of post-traumatic tinnitus and most importantly improve differential diagnosis of this common patient complaint and in that context, advance both diagnosis and treatment outcomes as related to this often frustrating and, at times, disabling sensory disorder symptom. Thank you to Dr. Deb Braunling-McMorrow, chief editor of BIP, for the opportunity to edit this issue of Brain Injury Professional.

about the guest editor
Nathan Zasler MD, FAAPM&R, FAADEP, DAAPM, CBIST is CEO & Medical Director for Concussion Care Centre of Virginia, Ltd., as well as Tree of Life Services, Inc. Dr. Zasler is board certified in PM&R and fellowship trained in brain injury. He is an affiliate professor in the VCU Department of Physical Medicine and Rehabilitation, Richmond, VA, and an adjunct associate professor in the Department of Physical Medicine and Rehabilitation at the University of Virginia, Charlottesville. He currently serves as Vice-Chairperson of IBIA. Dr. Zasler has published and lectured extensively on TBI related neuromedical issues and edited 6 textbooks including “Brain Injury Medicine: Principals and Practice”. He is co-chief editor of “Brain Injury” and “NeuroRehabilitation.” Dr. Zasler is active in local, national and international organizations dealing with acquired brain injury and neurodisability, serving in numerous consultant and board member roles. Dr. Zasler is an advocate, educator, clinical researcher, inventor, entrepreneur and busy practicing clinician who is involved with community based neurorehabilitation, chronic pain management, and international health care consultation.

To get full access to the edition or to all of the editions, please click here to join North American Brain Injury Society (NABIS).