Using Applied Behavioral Analysis to Improve Compliance in O&P

O&P devices require training, know-how, and expertise to fabricate, but even the best device cannot aid the patient if it is not used correctly. Reduced adherence to treatment plans alters the device's ability to reach therapeutic goals, regardless of the efficacy of clinical interventions. 1 An established relationship between noncompliance and poor clinical outcomes highlights how biomechanical and pathological considerations alone do not create an effective treatment plan; behavior must also be considered. 2 Applied behavioral analysis (ABA) is used to develop procedures that produce observable changes in behavior. 3 The goal of ABA is to identify why a behavior occurs and design intervention plans accordingly. Behavior interventions are not based on what behavior is performed, but rather why it occurs. Gathering information and critically analyzing behavior within clinical appointments can be used to understand patient intention, allowing the clinician to select and apply real-time interventions that can improve patient interactions and device compliance. ABA can increase occurrence of desired behaviors and decrease the frequency of maladaptive behaviors through analysis of current and past behavior patterns and the patient's history.

The first step to managing challenging behaviors is to identify the ABCs of behavior: antecedent, behavior, and consequence. Antecedent is what occurs before the behavior, including the stimulus events, situations, or circumstances that preceded a behavior. 4 Behavior can be under stimulus control, meaning the specific behavior occurs only in the presence of the particular stimulus. 5 The consequence is an event or social interaction that occurs immediately after the behavior and could influence the future frequency of the noncompliant behaviors. A consequence can reinforce a behavior and increase future frequency or punish a behavior and decrease future occurrences. 5 Merely blaming patients for noncompliant behaviors removes responsibility from clinicians and their ability to influence patient outcomes. Specific intervention strategies can be selected to address the underlying purpose of the behaviors. By identifying events that occur before or after noncompliant behavior, clinicians can identify the circumstances that increase or decrease the frequency of these behaviors. Parameters of reinforcement also influence behavior. Effort to gain reinforcement, such as size, magnitude, and intensity, should match the reinforce ment itself, otherwise the individual may not view the activity as reinforcing. 5 Clinicians and patients may not share the same perspective on the effectiveness of particular reinforcers, such as walking, mobility, and independence. The ABCs of behavior can be used to identify the function of behavior—why patients perform a particular behavior. The functional behavioral analysis identifies that behaviors are maintained or reinforced by one or more functions of behaviors: escape/avoidance; attention-seeking; access to tangible objects or activity; and sensory/autonomic. 5 Escape/Avoidance Maintained Behavior Escape maintained behavior presents as problem behavior that results in postponing or terminating aversive events, tasks, or less preferred activities. The maladaptive behavior is reinforced if the patient successfully escapes the task. 5 Some patients with disabilities may become dependent on caregivers and family members, and increasing mobility with O&P devices can suddenly introduce overwhelming expectations of newfound self-maintenance tasks. Through learned helplessness, the patients may avoid or escape increasing their independence by not using their devices as recommended. Control and counter-control is another aspect of escape maintained behavior, occurring when aversive controlling conditions elicit an escape or avoidance response. 6 Clinicians may be perceived as controlling when patients misinterpret the intentions of device selection, delivery, and education for proper use. Patients may not interpret the instructions as innocuous, but rather another trial that proves having a disability reduces personal choice and freedoms. These behaviors may be expressed toward clinicians who are delivering instructions or expressed against the disability itself, which patients may perceive as a central controlling factor in their lives. Increasing choices available to patients can increase their sense of control, and the resultant counter-control escape maintained behavior decreases. Building choices into appointments can be simple, such as design choice or preferred appointment times. These examples would not change how clinicians perform their jobs but can greatly improve how patients perceive interactions and decrease counter-control behaviors. Nonadherence can be reduced by addressing why patients are escaping a particular activity and creating a plan to reintroduce the activity into patients' lives. Discussing O&P patients' goals with them can make them feel more involved in their treatment plan and invested in achieving goals they set for themselves, thus reinforcing proper device usage. This function of behavior also applies to escaping social attention. 5 People with disabilities may experience social bias based on the perception of negative characteristics associated with disability. 7 Studies show between 49 and 64 percent of people with lower-limb amputations are neutral or dissatisfied with cosmesis of prosthetic devices. 8 Cosmesis can be the basis for behaviors mediated by escaping social attention. In the attempt to hide a visible disability and avoid stigmatizing reactions, patients may avoid public settings or may dress in a manner that hides their disability or devices. By acknowledging the specific function of behavior, the patient-preferred cosmetic device can address their concerns about social attention and reduce non-adherent behaviors. Attention-seeking Maintained Behavior Attention-seeking behaviors are identified as problem behaviors resulting from keeping or gaining attention from others and can be reinforced by either positive or negative attention, including soothing, consoling, reprimanding, scolding, etc. 5 Patients who make frequent calls and office visits may be engaging in attention-seeking behavior, especially if the frequency of contact increases when they receive social attention through additional phone calls or appointments. Providing attention reinforces attention-seeking behaviors, making it more likely to occur in the future, while reducing attention can decrease frequency of the behavior. Socially motivated behavior could be usefully redirected to activism, public speaking, or other socially engaging activities to fulfill the social purpose of patients' attention-seeking behavior. Access to Tangible Objects/Activity Maintained Behavior Maladaptive behaviors can also be maintained by gaining access to tangible objects or activities. Many new prosthesis users will overuse their devices initially, against the wear schedule prescribed. Overuse of a prosthesis is driven by access to previously restricted activities and reinforced by the preferred object or activity. Mobility as a reinforcer can be altered when patients experience pain or develop skin breakdown due to overuse. It can become a punishment and decrease future likelihood of engaging in mobility activities. Conversely, the increased mobility may be more reinforcing than the punishment of pain, resulting in patients walking through the pain. Instructing patients to use their devices less does not address the driving force behind their behavior. Behavior management can help find a compromise between the patients' underlying need for increased mobility and the advised treatment plan of gradual acclimation to their devices. Referring patients to physical therapists for exercises that can be performed throughout the day with or without a device can help address the patients' desire for mobility. This allows them to engage in physical activity and strength training that will improve future mobility without harming their limbs. Sensory/Autonomic Maintained Behavior Sensory or autonomic mediated behavior describes undesirable behaviors that result from automatic reinforcement (such as self-stimulatory behaviors) that are not socially mediated (such as refusing to wear a prosthesis or orthosis due to discomfort or pain). 5 The sensory feedback from the device drives the patient's noncompliant behavior to misuse or reject the device. Not all patients have the same sensory tolerance, which could result in the same device working perfectly for one patient and a device failure for another. Instructing patients to allow time to adjust to the new pressures may work for some individuals but does not address the underlying sensory/autonomic mediated behaviors of others. Patients dissatisfied with their devices may require constant and ongoing modifications and possibly fabrication of new devices altogether. Time and money are wasted in the clinic when patients' sensory needs are not addressed. Intervention Strategies Recognizing functions of behavior influencing noncompliance allows clinicians to address factors specific to each individual patient, thus improving the patient-clinician relationship and adherence rates. Once there is an understanding of patients' behavior, intervention strategies can be designed and implemented. Self-awareness is key to dealing with maladaptive patient behaviors and understanding how the behaviors can affect clinicians' feelings and subsequent behaviors. Four questions that can help clinicians assess problem behaviors in a clinic setting include: What am I feeling now? What does the patient want, need, or feel? How is the environment affecting the patient? How do I best respond? 9 This allows clinicians to self-reflect and express compassionate understanding of patients' behavior instead of casting judgement or blame. Active listening, or listening for meaning, is used to understand patients' point of view and feelings. It is based around empathetic communication of feelings, validating the patients' experiences, and taking patients' viewpoints into consideration without judgement. 9 Summarization helps reflect what patients say back to them, and reflecting the intensity of patients' emotions also demonstrates clinicians' desire to understand and validate patients' experiences. 10,9 Nonverbal responses facilitate communication without speaking. Silence allows patients to continue speaking without interruption and gives them ttime to vent and calm down when patients are frustrated. 9 Taking time away can also help defuse a stressful situation by removing social stimulation and allowing space and time for patients to regain composure. Other nonverbal techniques include nodding to express understanding, awareness of physical proximity to patients, facial expression, and eye contact. While eye contact can show an individual is listening, prolonged and unbroken eye contact can be intimidating and make patients feel uncomfortable. Similarly, proximity can show support but being too close can elicit feelings of anxiety or unease. The Life Space Interview (LSI) can help patients and clinicians understand difficult behaviors through exploration of feelings related to a particular behavior. 9 The LSI steps are to explore the patient's perspective; summarize feelings and content; connect feelings to behavior; discuss alternative behaviors; and plan for the next stressful event or difficult behavior. 9 Patients can get frustrated when problems arise in the clinic that prevent access to treatment or devices. By exploring patients' experiences and connecting the behavior to their feelings, a therapeutic space is created that opens the opportunity for behavior to be positively altered in the future. Hurdle help, another behavior intervention strategy, refers to clinicians' initial assistance help patients start on a task. Donning and doffing of devices can be frustrating for many patients. Helping with parts of the donning/doffing tasks can improve the patients' compliance with their devices, and assistance can be faded out as they learn the proper techniques. Nonadherence to a treatment plan is associated with lower functional levels and poor outcome measures. 12 One study reported orthotic device overuse due to symptom progression and the device's recognizably positive effects on the respondent's function. 13 Underuse resulted from resolution or abatement of symptoms, disappointing effect or lack of improvement, or an ill-fitting device causing pain or irritation. 13 The degree to which the orthoses solved subjects' medical problems and patient satisfaction with the device was highly correlated to device compliance. 13 Prosthetic users reported sensory feedback, function, comfort, and cosmesis as critical factors in determining device compliance and usage. 11 Patient behavior and noncompliance does not exist in a vacuum, but rather is a complex interaction with the world at large and their personal histories. Placing blame on patients for choosing to not follow medical advice is a severe oversimplification of the problem and does not address why patients present noncompliant behaviors. By investigating what the specific behavior is and what purpose the behavior serves, clinicians can shift from blaming patients to a place of understanding and compassion. This does not mean all behavior is acceptable because it can be explained. Understanding patients' motives can enlighten clinicians to change their own behavior to achieve the best results from their patients. Emma Newland has an MSPO from the University of Pittsburgh and a bachelor's degree in neuroscience. She spent two years working as an ABA behavior therapist for children with disabilities. References

[1] Thatipelli S, Arun A, Chung P, et al. Review of Existing Brace Adherence Monitoring Methods to Assess Adherence. Journal of Prosthetics and Orthotics. 2016;28(4):126-135. doi:10.1097/jpo.0000000000000106.

[2] Leichter SB. Making Outpatient Care of Diabetes More Efficient: Analyzing Noncompliance. Clinical Diabetes. 2005;23(4):187-190. doi:10.2337/diaclin.23.4.187.

[3] Baer, Donald M., et al. "Some Still-Current Dimensions of Applied Behavioral Analysis ." Journal of Applied Behavior Analysis, vol. 20, no. 4, 1987, pp. 313–327., doi:10.1901/jaba.1987.20-313.

4[14] Johnston, James M. "‘Replacing' Problem Behavior: An Analysis of Tactical Alternatives." The Behavior Analyst, vol. 29, no. 1, 2006, pp. 1–11., doi:10.1007/bf03392114.

5[13] Barretto , Maile. Behavior Technician Training Manual . A Is for Apple, Inc. Autism, Speech, and Occupational Therapy, 2016.

6 [15] Delprato, Dennis J. "Countercontrol in Behavior Analysis." The Behavior Analyst, vol. 25, no. 2, 2002, pp. 191–200., doi:10.1007/bf03392057.

7 [16] Dunn, Dana. The Social Psychology of Disability. Oxford University Press, 2015.

8 [17] Cairns, Nicola, et al. "Satisfaction with Cosmesis and Priorities for Cosmesis Design Reported by Lower Limb Amputees in the United Kingdom." Prosthetics & Orthotics International, vol. 38, no. 6, 2014, pp. 467–473., doi:10.1177/0309364613512149.

9 [20] Holden, Martha J. Therapeutic Crisis Intervention for Schools . Edited by Michael Nunno, First ed., Residential Child Care Project, Cornell University , 2012.

10 [19] Perry, Bruce Duncan, and Maia Szalavitz. The Boy Who Was Raised as a Dog: and Other Stories from a Child Psychiatrist's Notebook: What Traumatized Children Can Teach Us About Loss, Love, and Healing. Basic Books, 2017.

11 [9] Biddiss EA, Chau TT. Upper limb prosthesis use and abandonment: A survey of the last 25 years. Prosthetics and Orthotics International. 2007;31(3):236-257. doi:10.1080/03093640600994581.

12 [10] Pernot H, Witte LD, Lindeman E, Cluitmans J. Daily functioning of the lower extremity amputee: an overview of the literature. Clinical Rehabilitation. 1997;11(2):93-106. doi:10.1177/026921559701100202.

13 [11] Dijcks BPJ, Witte LPD, Gelderblom GJ, Wessels RD, Soede M. Non-use of assistive technology in The Netherlands: A non-issue? Disability and Rehabilitation: Assistive Technology. 2006;1(1-2):97-102. doi:10.1080/09638280500167548.

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