This paper is adapted from a paper given at the 6th State Conference of OT Australia-NSW, Mudgee, NSW, 1993.

Jodie Nicholls, BAppSc(OT),GradCertAppSc(OT) in Neurology, is an occupational therapist at the Brain Injury Unit at Westmead Hospital, Westmead, NSW.

Christine Chapparo, MA,DipOT,OTR,FAOTA, is a senior lecturer at the School of Occupational Therapy, The University of Sydney, NSW, and a clinical consultant to the Brain Injury Unit, Westmead Hospital

PURPOSE

This paper outlines an approach to intervention of one of the more difficult levels of cognitive recovery in head injury: the client who is progressing through the stage of extreme agitation. The paper contains an outline of the following.

1.	A description of agitated behaviour
2.	A model of systematic instruction that can be used with clients in this phase of recovery.
3.	A case study which illustrates how intervention can be applied to reduce agitated behaviour and promote occupational performance.

DESCRIPTION OF AGITATED BEHAVIOUR OCCURRING AFTER BRAIN IMPAIRMENT

The classification of agitation is derived from the Rancho Los Amigos Stages in Cognitive Recovery Scale (Hagen, 1981; Ylvisaker, 1985). This behavioural scale describes reorganisation of cognition relative to eight levels from Level 1 (vegetative state) to Level VIII (approaching normal function). Agitation is a critical feature of Levels IV and V. At these levels, the scale clearly defines the behaviours demonstrated by clients in the following way.

1.	An inability to follow any complex commands without the presence of an external structure. This results in non purposeful responses and an inability to achieve any desired occupational performance goals.
2.	Agitated behaviour that may or may not be a direct result of external stimulation and is considered out of proportion to that of the stimulation.
3.	An inability to focus attention to a specific task or subtask without frequent redirection.
4.	Inappropriate verbalisation with confabulation being triggered by environmental events.
5.	A severely impaired memory with the confusion of present and past events in reaction to ongoing personal and environmental activity.
6.	An inability to initiate occupational performance tasks
7.	Inappropriate use of everyday objects.
8.	An inability to learn new information although performance of previously learned tasks may occur in a structured environment
9.	A desire to wander in those clients who are physically able, and restlessness in those who are not, with an intention of ‘going home’.

IMPACT OF AGITATION ON OCCUPATIONAL PERFORMANCE

The impact of agitation on a client’s occupational role performance is devastating. The inability to attend to any task, coupled with the confusion about events, people, places and objects, causes the clients to become totally dependent on others for all aspects of life. It is also clear from observation that the agitated behaviour limits the client’s social interactive roles due to the ‘out of proportion’ response to external stimulation. Clients at Level IV or V can be both verbally and physically aggressive and are often unable to differentiate between medical staff and relatives. This leads to limited social interaction, isolation from significant other persons in the client’s life and development of further disordered role behaviour over time. The behaviours that accompany agitation are viewed as one of the greatest barriers to engagement in chosen or needed occupational and social roles. Agitation, when severe, can result in danger to the client, family and staff and can result in reduction or cessation of intervention.

While the Rancho Los Amigos Scale (Hagen, 1981) clearly defines the difficulties and goal expectations of this level of recovery, there is little or no guidance from the literature regarding the actual therapy approach that is most successful. Staff at the Brain Injury Unit, at The Westmead Hospital began to apply principles of systematic instruction to restore client performance of occupational tasks and roles. The need to examine more specific methods to instruct these clients arose when the Unit began to admit increasing numbers of clients with agitated behaviour. It was clear that staff from all professional groups were at a loss as to the best way to manage these clients who were often physically abusive. Occupational therapy became one of the primary forms of therapy at this point in their recovery.

SYSTEMATIC INSTRUCTION PRINCIPLES AND APPLICATION TO CLIENTS WITH AGITATION

Systematic instruction, when used as an intervention method in occupational therapy, is a model of teaching occupational tasks that is drawn from the body of knowledge of cognitive behaviour theory. Several assumptions underlie this approach and form the major principles of its application to this client group (Donelly, 1994; NSW Dept. of Education, 1980; Snell, 1987).

1.	People respond to variables in their environment. Agitated behaviour as seen at Level V of the Rancho Los Amigos Cognitive Levels (Hagen, 1981) is directly related to stimulation from the environment. It is possible therefore, to restructure the environment to reshape behaviour and teach clients self maintenance tasks.
2.	Behaviour is an observable, identifiable phenomenon. Systematic instructional approaches concentrate on observable behaviours in the here and now and work to change the observable behaviour. At Level V, the observable behaviour is usually one or more manifestations of agitation, as outlined above.
3.	Maladaptive behaviour are acquired through learning and can therefore be modified through learning. At Level V, reports indicate that the client actually learn agitated behaviour patterns through a process of negative reinforcement. By changing the environmental stimulus, and the reinforcement patterns, behaviours will also change.

PHILOSOPHICAL ASSUMPTIONS THAT UNDERLIE SYSTEMATIC INSTRUCTION FOR PEOPLE WITH AGITATION IN AN OCCUPATIONAL PERFORMANCE CONTEXT

According to the Occupational Performance Model (Australia), (Chapparo & Ranka, 1996), people are active participants in creating their own occupational being. Occupational therapists assist the client and family to develop aspects of occupational role performance that are chosen or needed by the client and/or their social environment. It is the view of the authors that any instruction given to modify behaviour will be given relative to the client and family need. It is therefore not acceptable to modify agitated behaviour merely because it is behaviour that is viewed as inconvenient to the staff, or unusual.

INVOLVEMENT OF STAFF AND FAMILY IN OCCUPATIONAL PERFORMANCE GOALS

Agitation and its associated behaviours is usually perceived as an impediment to intervention by all staff who interact with clients. Clients who are at Level IV or V (Hagen, 1981) are cognitively dependent, requiring therapy, nursing and family input for all occupational tasks and routines. Daily routines become a battleground that is characterised by physical and verbal abuse. Often, the agitation at this stage of recovery is interpreted by family and staff as being personally directed at them. Before any instructional program is implemented, understanding of the following parameters of agitation are necessary. There must be frank recognition that:

*	agitation behaviours are a result of the brain injury and that a distinction must be made between the person and the agitated behaviour
*	the client is unable to recognise that agitation is causing distress or is inappropriate
*	the client is unable to initiate changes to agitation behaviours without assistance
*	all clients have performance strengths that can be used to change behaviour
*	modification of agitation has to be planned by all staff and family members if they are to be effective

PHASES OF SYSTEMATIC INSTRUCTION

There are four phases to a systematic instruction programme that supports performance of occupational routines and tasks:

Phase One

Involves defining the target behaviour and specifying the desired outcome. For example, in the case that is discussed in this paper, the target behaviour was initially eating with a spoon and the desired outcome was independence in this task.

Phase Two

This phase involves evaluating the client within various contexts to determine how behaviours change in relation to different environments. For example, the client in this case study was socially appropriate and more responsive to requests given to her by male members of staff.

Careful assessment of the client’s agitated behaviours is required before any instruction is implemented. Descriptions of the nature of agitation should include the circumstances in which agitated behaviours occurred over a number of days. From the perspective of occupational performance, it is important to record the following:

*	what task the person was doing
*	how people around the client responded to the behaviour
*	whether the person avoids engaging in occupational performance as a result of the behaviour
*	whether the person gains access to a particular task or object after the behaviour
*	particular events that seem to improve agitation; make it stop, or make it worse

Phase Three

Involves making decisions about the environment in which the therapy will take place and selecting positive reinforcers based on information gained in phase two. For example, in the case outlined in this paper, a decision was made that the client would be treated by herself, in a non-distracting environment. The reinforcer was determined by her most frequent request when she was in therapy.

Positive consequences must be meaningful. This refers to the consequence being perceived as truly desirable to the person, not the therapist. Consequences are effective if they are obvious and follow the behaviour to be taught immediately. This establishes a strong learning link between the task behaviour that is desired and the positive consequences of the performance.

Phase Four

This phase involved instructing the client in the task to be learned by breaking down the task into achievable steps During the instruction, reinforcement schedules are maintained and the number of steps of the task are gradually increased. For example, in the client case discussed in this paper, eating was the determined task with the ability to increase the number of spoonfuls eaten within a therapy session.

The remainder of this paper describes how these phases were applied to intervention for a client who is at Level Five – showing agitated, confused and inappropriate behaviour.

ANNA

Anna was a 33 year old woman who was involved in a motor vehicle accident in February. The accident occurred in the USA while she was attending her mother’s funeral. She sustained injuries which caused a right frontal subarachnoid and subdural haematoma. In September, following the accident, Anna was transferred to Westmead Brain Injury Unit to commence active rehabilitation. She had remained in a comatose state until one month before this transfer, with all prior medical expectations that she would die as a result of the injuries sustained. Anna was married with two young children.

Occupational Performance Assessment

When seen by the occupational therapist, Anna had marked agitation, making implementation of nursing and therapy programmes impossible. Her agitation was so extreme that she was unable to consistently recognise family members, including her own two and four year old children.

Anna was incapable of attending to any task presented. Her conversation was abusive and at times, sexually provocative to staff members. She demonstrated consistent confusion for events, places and people, with a total inability to recall her mother’s death.

Anna was dependent in all areas of self maintenance, of particular concern was eating and mobility. Anna’s abusive, agitated behaviour dramatically increased any time therapists or nursing staff attempted to engage her in these routines. She was therefore fed by means of a gastrostomy tube, although assessment revealed that there was no biomechanical reason for her inability to swallow.

INTERVENTION TO REDUCE AGITATION AND ENHANCE OCCUPATIONAL PERFORMANCE

Phase One

The Occupational Performance Model (Australia) is used in this context as a ‘top-down’ model. Occupational need of any client is determined relative to occupational roles that are needed or chosen by the client or significant others in the social environment. In Anna’s case, it was necessary for survival that she assume more responsibility for her own occupational role as a self maintainer by eating. Her family needed her to assume aspects of her expected role as a family member, as they expected Anna to live back at home with them in the future. Anna’s own personal choice was to engage in full time rest. A balance of these role expectations, derived from both personal and collective aspects of Anna’s life was needed.

The immediate goals, therefore centered on her eating, grooming, showering and dressing. Due to the complexity of showering and dressing, it was decided to concentrate on eating for the following reasons. First, it was necessary for health reasons that Anna start eating and drinking. Second, it is a simple, continuous task that occurs many times throughout the day, thereby offering natural repetition and practice opportunities. Third, it provided her family with an opportunity to be involved in her intervention in the role of family members sharing a meal.

Phase two

The decision was made to treat Anna in a non-distractible environment, with only one person making behavioural requests. This decision was made relative to her high levels of distractibility and severely limited attention.

Phase three

A meaningful reinforcement system was created using a positive reinforcer that was truly desired by Anna. She made continuous requests throughout the day to lie down and rest. This became her reinforcer. It was behaviourally appropriate, supported her need to rest, as well as being able to be immediately implemented.

Phase four

This phase involved the actual instruction during therapy. Anna was positioned in a comfortable sitting position at mealtime and requested to take a mouthful of food. The request was kept simple, directive and repeated until the mouthful was eaten. When the food was swallowed, Anna was then able to lie down for a short period. When the request to eat was given and Anna continued with her agitated and abusive behaviours, she was asked to repeat the request (to eat one spoonful) plus the consequence (lying down) to eat back to the therapist (‘if I eat, then I can lie down’). This vocalisation of her intended action assisted her performance dramatically. Getting Anna to repeat the instruction provided her with the opportunity to learn to problem solve and to learn 1) to direct her own actions, and 2) to learn the consequences of her actions (‘If I do ……, then this will happen’). This laid down the foundation for problem solving strategies during more complicated self maintenance tasks and routines. The vocalising of actions indicated that her attention had been captured and the requests had been processed.

PROGRESS

In the first therapy session, utilising this approach, Anna spent the majority of the time verbally abusing the therapist. She did eventually consume one mouthful of food in 60 minutes. This was, however, the first time in two months that Anna followed a direct request and participated in an occupational task. It was viewed by the therapist and her family as a major achievement. With the continuation of this approach, Anna improved her eating routine performance rapidly to independent eating within three weeks. The time between the request to eat being given and her actual eating performance decreased and Anna was eventually able to consume one whole meal in a therapy session and later with her family.

As Anna’s ability to eat increased, the amount of agitated behaviour dramatically decreased. This occurred in response to her limited attentional ability being focussed on one functional task.

Once independent eating had been achieved, the goal of independence in drinking and grooming routines were quickly established. The same techniques and reinforcement system was used.

The challenge at this stage of therapy was to increase her performance in occupational tasks and routines without the need for an artificial reinforcer. This was achieved by gradually increasing the number of steps required to be performance before the reinforcer was given.

Finally, when mastery was evident in the tasks learned, the task itself and her control over it became the driving force for completion.

With independence in grooming achieved, therapy goals centered on showering and dressing. Due to the complexity of these tasks, a structure or routine was created to assist her learning. Anna was directed to undress, wash and redress in a very structured and specific sequence. This sequence remained consistent throughout her stay within the unit. As she began to learn her showering routine, Anna would spontaneously vocalise her intended actions, keeping herself on track. This created a functional self prompting mechanism.

Discharge

On discharge from Westmead Brain Injury Unit, Anna was able to:

*	eat independently with her family
*	independently comb her hair, brush her teeth, apply hand cream and makeup when given the objects required
*	undress and wash herself with minimal initial prompt

Apart from these gains in mastery of occupational performance tasks and routines, her agitated behaviour had decreased dramatically, and was only exhibited in times of physical stress and pain. Even during this events, little physical aggression occurred and there was use of socially acceptable language. Anna recognised her family members more consistently and began engaging in appropriate social interaction with them. She also began to inconsistently recall events, including her mother’s death, though her time frame remained confused.

PERSONAL AND CONTEXTUAL CONSIDERATIONS

A number of personal and contextual considerations became apparent and were important to the success with which Anna’s agitation was managed by therapists.

Contextual

While there are a small number of brain injury units designed specifically to manage clients with agitated and aggressive behaviour, this was not the case at Westmead. As with the majority of Brain Injury Units, staff at Westmead are expected to manage clients who have a broad range of problems to varying severity. In this context, difficulties posed by clients with agitation are enhanced. It is important that team and family members understand the nature of agitation and learn to identify and predict succeeding stages of recovery. The Rancho Los Amigos Cognitive Stages of Recovery (Hagen, 1981) are useful for this purpose.

Personal

For therapists, frank recognition of the personal difficulties involved in managing clients with extreme agitation is imperative. The following are guidelines to cope with these difficulties over time.

*	Learn to identify the presence of agitation before it escalates to physical violence.
*	A ‘team’ of people who are trained to manage severe agitation may be the best option where physical safety is seriously questioned.
*	Therapists who are the focus of aggressive or abusive client outbursts over time need to be given opportunities to talk through their experiences.
*	It is helpful to have a ‘mentor’ who is knowledgable about agitation, and the possible course of intervention so that supervision may be sought.
*	It is imperative to have a guiding framework through which, step by step plans can be made to guide both clients and therapists through this difficult period of recovery. The Occupational Performance Model is one such framework, as it offers explanations about the possible relationships that exist between cognition and other component functions, as well as cognition and tasks, routines, roles and environmental influences. From this theoretical base, therapists are able to explain their intervention, and predict outcome.

SUMMARY

Principles of systematic instruction, when applied within the context of meaningful occupational performance to clients with severe agitation following traumatic brain injury, work to improve performance of occupational tasks and establish functional roles.

Through a case example of one client, this paper presented step by step guidelines illustrating how principles of systematic instruction can be applied within an occupational therapy context to manage extreme agitation and facilitate useful occupational task and role performance. Using this approach, therapists find that:

1.	It assists to more specifically define therapy goals relative to steps of a task that are measurable
2.	It gives specific directions about the focus and type of instruction required.
3.	It assists them to overcome the natural apprehension that occurs when dealing with clients who extremely agitated, and physically and verbally abusive.

REFERENCES

Donelly, M. (1994). Systematic instruction: Study guide. Graduate Certificate in Applied Science (Occupational Therapy in Neurology) Available from School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Lidcombe, NSW. Australia.

Hagen, L. (1981). Language disorders secondary to closed head injury: Diagnosis and treatment. Topics in Language Disorders. 1, 73-87

New South Wales Department of Education (1980). Strategies for teaching students with severe intellectual disability. Sydney: NSW Department of Education.

Snell, M (1987). Systematic instruction of persons with severe disability. (3rd ed.). Columbus: Merrill

Ylvisaker, M. (Ed.). (1985). Head injury rehabilitation: Children and adults. London: Taylor & Francis