Behavior Modification Protocols on a Pediatric Adolescent Unit

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Behavior

Modification

Protocols

on a Pediatric

Adolescent

Unit

Joseph L. Woolston, MD, and John E. Schowalter, MD

From the Department of Pediatrics, Yale-New Haven Hospital, and The Yale Child

Study Center, New Haven, Connecticut

ABSTRACT. The use of operant conditioning protocols

for the management of behavioral disturbances of

hospi-talized adolescents with serious chronic medical illnesses is discussed in this paper. The use of the protocol from the point of view of changing hospital staff interaction is

emphasized. Three cases are used to illustrate the process

by which the protocol is created and its therapeutic effect

on the patient and staff. Pediatrics 66:355-358, 1980;

behavior disorders, operant conditioning protocoLs.

The use of operant conditioning techniques as a

method of increasing staff morale and solidarity

and decreasing hospital management problems in

patients with serious chronic illness is discussed.

The techniques were suggested by child psychiatrist

consultants for patients in the adolescent ward of a

general hospital. The setting has been described

previously by Jankowski’ and Schowalter.2

Operant conditioning techniques have been used

to treat a broad spectrum of behavioral

disturb-ances in children. The literature of this use is

exten-sive and voluminous.7 Ross8 and Werry and

Wol-lersheim9 have written comprehensive overviews of

the field of behavior modification of children and

have included both the relevant theoretical points

as well as the clinical applications.

There has been an entire spectrum of articles

directed toward applying behavior modification to

problems specific to pediatrics. Several general

re-views9’2 have described many of the basic concepts

of behavior modification and their direct

applica-tion in pediatrics. Drabman and Jarvie’3 described

solutions for the most common difficulties

pediatri-cians have in counseling parents of children with

behavior problems.

Received for publication Oct 24, 1979; accepted Jan 3, 1980. Reprint requests to (J.L.W.) Yale University Child Study Cen-ter, 333 Cedar St, New Haven, CT 06510.

American Academy of Pediatrics.

The use of behavior modification in eating

dis-orders has attracted considerable attention.

Brow-nell and Stunkard14 reviewed the relevant literature

in the behavioral outpatient treatment of

obe-sity. A variety of studies’’7 on the inpatient

treat-ment of anorexia nervosa has indicated that operant

conditioning techniques are powerful tools in the

therapeutic armamentarium.

Few authors have commented on the limitations

and contraindications for behavior modification.

Schowalter’8 enumerated several cautions about

naive application of behavior modification tech-niques. First, all behavior begins as communication

and so annoying behavior should be listened to as

well as attacked. Second, since all children are

different, their treatment should be carefully

mdi-vidualized to meet their special developmental,

cog-nitive, and emotional needs. Third, simply

extin-guishing a “bad” behavior is not enough: a more

acceptable behavior should be encouraged to fill

the vacuum left by the extinguished one.

Despite this increasing body of literature

describ-ing the use of operant conditioning techniques in

schools, hospitals, outpatient clinics, and

psychiat-ric and penal institutions, little has been written

about the effect that these techniques have on staff

members and how this impact can enhance the

management of behavior disorders which

compli-cate inpatient pediatric treatment. To do this is the

purpose of the present communication.

METHOD

The first task in developing a behavior

modifi-cation protocol is to identify specific objectionable

behaviors. This is accomplished by a meeting with

the staff involved (nursing and house staff, social

worker, school teacher, dietician, physical

thera-pists). This collaborative meeting is important

be-cause it also serves a second series of tasks: to

increase morale, clarify goals, and decrease staff splitting and divisiveness.

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356 BEHAVIOR MODIFICATION ON A PEDIATRIC ADOLESCENT UNIT

Schwartz’9 as emotional and intellectual

polariza-tions which antagonize staff members against one

another and disrupt teamwork and morale. The

deleterious effects of this phenomenon preclude the

setting of effective, consistent rules for patients.

The resulting disharmony and inconsistencies are

frequently at the heart of many behavior

manage-ment problems on the ward. When staff splitting

occurs, one group is perceived as too harsh and

punitive, while the other group is perceived as “soft

headed” and “spoiling.” With a minimum

manipu-lative effort a patient can maintain this

disorgani-zation since the dysfunctional system tends to be

self-perpetuating. Thus, the process of a meeting of

all the staff involved in the patient’s care usually

has a salutary effect, especially when clearly defined

and written behavior goals are decided upon by

concensus.

The next task is to perform a psychiatric

assess-ment of the various

factors

contributing to the

patient’s behavior (eg, psychosis, organic brain syn-drome, grief reaction, personality disorder). This is

done through three or four individual sessions with

the patient. These

meetings

with the patient also

determine positive behavioral reinforcers and elicit

the patient’s collaboration with medical care. To be

maximally effective, the protocol must involve the

patient as a partner from its inception.

A behavior modification protocol suitable for the

individual patient is then written. Two basic aspects

are incorporated in

every

plan: the patient is put in

a private room so that the staff can exert control over reinforcers; and the patient is started at a base

line of privileges, which include free access to all of

the activities of the floor. In order to maintain this

base line, the patient is required to keep this

objec-tionable (and clearly specified) behavior to a low

level. If he cannot do this, he is restricted to his

room for a specified (usually short) period of time.

If the behavior persists, he is restricted to his bed, again for a specified period of time. If, on the other

hand, the patient is able to decrease markedly his

objectionable behavior (again in a clearly specified

manner), then he is given the highly desired

rein-forcers (eg, walk outside, increased access to crafts

or recreational therapist) discovered in the initial

interview.

Once outlined, the protocol is discussed in a

sec-ond staff meeting and during another interview

with the patient. The final draft is then written and

distributed to the patient and to all of the hospital

staff involved in the patient’s care. This wide

dis-tribution serves to solidify staff cohesiveness.

RESULTS

The following three case histories illustrate

re-sponses to this procedure.

CASE REPORTS

Case 1

N.M. was a 12-year-old, second generation Yugoslav-ian-American girl who received second- and third-degree

burns over 70% of her body in a house fire when she was 9#{189}years old. Her mother was killed and her home was

destroyed by the fire. She spent the next seven months in her local hospital recovering from the burns. After that hospitalization she was repeatedly admitted to the

Ado-lescent Inpatient Service for extensive plastic surgery

repair. Because of behavioral management problems, one

ofus (J.L.W.) was asked to see her on her sixth admission.

She was described by the staff as manipulative,

negativ-istic, combative, abusive, unmanageable, and unpredict-able. When interviewed, she had a strong histrionic flair to her personality, with flirtatiousness, lability of affect, and tremendous neediness. A further complication of her

management was that her father was a violent alcoholic

who spoke no English.

Her protocol used access to specified recreational op-portunities and staff attention as the positive

contingen-cies. Base line was set at full ward activities. If she was found to be assaultive, abusive, or disruptive, she was told that she would need a quiet period of five minutes in her room. If she could still not control herself (eg, de-stroyed furniture, threw objects), she would be put at bed

rest for a specified period of time.

Immediately after the protocol was developed her

be-havior improved dramatically, as did staff morale.

Al-though she did require some quiet periods, she never

needed bed rest. She tested the protocol in various ways, including causing her father to get very angry toward the

head nurse. Fortunately, because the protocol had been

developed by the entire staff, no wavering occurred.

N.M.’s behavior has remained improved over the last ten

months of repeated admissions. Virtually no return of

disruptive behavior has occurred.

Case 2

T.J. was a 14’/3-year-old black girl admitted for the third time in a six-month period for treatment of acute

myelocytic leukemia. Before the onset of this illness she

had been an active, mostly unsupervised, teenager. She

dealt with her illness through denial, especially as shown

by her poor adherence to the treatment regimen. After

five months of chemotherapy she was readmitted for

work-up of lower back pain. Extensive investigation

re-vealed a mass lesion compressing the spinal cord.

Al-though emergency radiotherapy was given, she was left

with a permanent paraplegia. One of us (J.L.W.) was

asked to help with behavioral management, because she

became assaultive, abusive, manipulative, and uncooper-ative. In the individual interviews, it was learned that

much of her behavior was not surprising, given the

corn-bination of her prernorbid personality, her anger at the staff, and the fact that she was in mourning for her past

health and the anticipation of her possible death. The

staff in turn was overwhelmed with guilt which paralyzed them in their attempts to set reasonable rules. In addition,

there was great confusion about the appropriate goals

required for discharge. The three major ones decided

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upon were bowel training, ability to transfer from bed to wheel chair, and self-catheterization.

The protocol emphasized T.J.’s cooperation. She

helped make a chart which listed each goal and then

made check marks each time one was achieved. Like

N.M., she would be confmed to her room alone for five

minutes if she was assaultive or abusive.

Her behavior changed immediately after the protocol

was developed, and no negative reinforcers were used.

The remainder of her hospital course was uneventful and she was discharged to home a week later without incident.

For eight months she maintained adaptive rehabilitation skills and continued to cooperate with her medical

treat-ments until death from leukemia.

Case 3

O.S. was a 163/4-year-old white boy transferred from a community mental health inpatient facility for emergency

treatment of acute pancreatitis and severe cachexia sec-ondary to a three-year history of anorexia nervosa. In the

past he had been treated for 12 months in outpatient family therapy, for two months on a university psychiatry inpatient service, and 18 months on the inpatient service of a private psychiatric facility, all without appreciable benefit. When treated with an antidepressent, he devel-oped hypertension. A trial of phenothiazine caused neu-tropenia, and that medication was discontinued. Several attempts at operant conditioning had resulted in failure.

Shortly after admission to the ward he developed Gram

negative sepsis from his peripheral hyperalimentation and had a cardiorespiratory arrest. Since every attempt at oral refeeding resulted in an exacerbation of his pan-creatitis, it was decided that he would require many

weeks of intravenous hyperalimentation. Unfortunately but characteristically, he persistently sabotaged intrave-nous therapy by manipulating the apparatus in such a way that the intravenous line clotted or infiltrated every eight to ten hours. Since he was rapidly running out of

peripheral veins, a central venous line was considered as the only alternative. The danger of infection, embolism,

and pneumothorax with a central venous line were

con-sidered high, given O.S.’s propensity for noncooperation.

One of us (J.L.W.) was asked to help manage his general

manipulative, uncooperative behavior as well as the spe-cific problem of his intravenous therapy.

Following the general method of the protocol, a

pro-gram was devised which placed him at base line if his

intravenous line lasted more than 12 hours. If it lasted longer than 24 hours, he was taken outside to the solarium for 15 minutes. On the other hand, if the intravenous

lasted between six and 12 hours, he was confined to his room until it had run for 12 hours. If it had only run from zero to six hours, he would be confined to bed until it had

run for six hours and confined to his room until it had run for 12 hours. Thus a stepwise system of progressive privileges was established which was directly contigent

on the patency of his intravenous line.

0.5. tested the protocol by having his intravenous line infiltrated within the first two hours. After that every one of his intravenous lines lasted for more than 30 hours and most were limited only by the medical requirement that they be changed every 36 hours in order to avoid sepsis or thrombophiebitis.

Although he remained a very difficult patient to treat both medically and psychiatrically, his intravenous man-agement was dramatically simplified, and this improve-ment was crucial in the eventual success of his medical management. In addition, staff esprit de corps was vastly

increased so that effective handling of his other behavior

problems could occur. Four months after discharge to

outpatient therapy, O.S. has continued to gain weight, slowly, but for the first time in more than three years.

COMMENT

The use of an operant conditioning protocol

ap-pears to be an effective adjuvant in the

manage-ment of behavior problems of severely and

chroni-cally ill patients. The explanation for this efficacy is complex. Slone et al#{176}demonstrated that certain

interpersonal factors normally associated with

psy-chotherapy, such as transference, catharsis and

trust, may be as important as the conditioning

techniques in understanding the process of behavior

therapy. In addition, Klein2’ has suggested that

behavior therapy represents the communication of

a therapeutic paradox. The paradox is that the

therapist devises a therapeutic structure which

forces the patient to be in control of the negative

and positive contingencies.

In this study the process of the development of

the protocol was probably as important as the

spe-cifics of the protocol itself in determining a

benefi-cial change in patient behavior. To be effective, we

believe this developmental process must include

multidisciplinary staff meeting so that the staff

splitting is reduced to a minimum, and interviews

with the patient to communicate concern and enlist

his collaboration with the program. The

establish-ment of firm, mutually agreed upon, nonpunitive,

consistent rules that reduce staff splitting is crucial. In our experience, the modification of staff behavior

is as important a response to the structure of the

protocol as is the patient’s response. The enhanced cohesiveness provides positive operant conditioning

for all. As Stanton and Schwartz’9 noted from their

work in a psychiatric inpatient setting, a patient’s

disruptive behavior often terminated abruptly when

staff members were brought together to discuss

their points of disagreement in the plan for the

patient’s care. We have found that the process

necessary to establish a behavior modification

pro-tocol for disruptive medically ill adolescent

inpa-tients provides an excellent forum to enhance staff

collaboration, consolidate agreement for a

treat-ment plan, communicate clearly the wish to be

helpful, and convince the patient that the staff is

united in its approach. As a consequence of these

messages, deviant behavior is reduced and often

eliminated.

Several important potential pitfalls in applying

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358 BEHAVIOR MODIFICATION ON A PEDIATRIC ADOLESCENT UNIT

problem of developing true staff concensus. If the

initial process of staff discussion is incomplete, there is a danger of having covert disagreements

even in the face of apparent overt concensus. The

ensuing double message transmitted to the patient

may actually exacerbate the behavior to be

elimi-nated. The usual roadblocks to full staff concensus

include realistic scheduling problems of different

disciplines, rotating shifts of nurses, and frequent changes of house staff. In addition, the presence of

unresolved past conflicts and jealousies between

departments, disciplines, or individuals makes

res-olution of current differences more complex, if not

impossible. Fortunately, discomfort with the

partic-ular clinical problem faced often provides the

im-petus to overcome these roadblocks.

A second set of potential problems arises with

the patient. Sometimes because of psychiatric

dis-ability the patient is unable to choose between

continuing behavior and receiving negative

contin-gency or adopting another behavior with its

contin-gent positive result. At other times this approach

cannot be used because the unacceptable behavior

is so noxious or dangerous (eg, homicide, suicide, or

other life threatening activities) that providing a

choice is not appropriate. Finally, a patient may be

able to choose and be given a choice but refuse to

enter into the arrangement. In our experience this

result is rather rare when the staff is cohesive and

the patient is approached with empathy and a spirit

of cooperation.

SUMMARY

Behavior modification protocols can be effective

tools in the management of behavioral disturbances

of hospitalized adolescents with serious chronic

medical ifinesses. To a considerable extent efficacy

depends upon the ability of the protocol to provide

structure so that patient-staff and staff-staff

inter-actions are less often misdirected. Although there

are contraindications to its use, the process

de-scribed of developing and implementing a protocol

usually has a salutary, and sometimes a dramatic,

effect.

ACKNOWLEDGMENT

This study was supported by US Public Health Service

grant 5T01 MH05442-28.

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1980;66;355

Pediatrics

Joseph L. Woolston and John E. Schowalter