Just posting this information about what a neurobehavioral milieu looks like in practice. This contains info from my experience at the Meridell Achievement Center (several years ago) and info from the Internet. Meridell offers two types of programming: traditional behavioral and neurobehavioral. This describes the qualities of a neurobehavioral program for higher-functioning individuals without an intellectual disability (Full-Scale IQ over 70).
Assessments should be conducted at admission to determine appropriate strategies and goals, including medication selections.
The assessment process should start with a neurophysiological examination, involving a Quantitative EEG with Evoked Potential (QEEG) or Cognitrace Study, reviewed by a Neurologist in consultation with a Neuropsychiatrist / Neuropsychopharmacologist, to determine the presence of a neurological-based psychiatric disorder. The Cognitrace Study, or Complex EEG with Auditory and Visual Evoked Potentials, is a non-invasive (no needles), brain imaging examination interpreted by a Neurologist trained in neurobehavioral disorders especially those related to aggression.
Positive findings will allow for precise medication selection which can offer more immediate relief of impulsive, explosive aggression.
Testing typically takes about one hour.
A Neuropsychiatrist will recommend medications to treat the affected brain areas and stabilize behavior based on the Neurologist’s report.
When the individual is stabilized on medication, there should be neuropsychological testing, including tests for IQ, Memory, Executive Functioning, Language, Motor, Achievement, Psychological Testing, and Diagnostic Interview.
There should be projective psychological testing to determine symptoms of psychiatric illness and type of personality.
There should be Neuropsychiatrists, Clinicians (LCSW, LPC, etc.), Program Staff, Discharge Planners, Neuropsychologists and Neurologists, on the treatment team.
There should be suites for QEEG testing and neurophysiological evaluation in the medical areas for higher-functioning individuals.
Intensive programming is provided each day, including psychoeducational groups, skills groups, processing groups, recreational therapy groups, and additional recreational, therapeutic activities.
Therapy interventions are evidenced-based and informed by models including Cognitive Behavioral Therapy, Systemic Family Therapy, Collaborative Problem Solving, Dialectical Behavioral Therapy, EMDR, and other trauma and relational models. Individual and family therapy is offered every week.
Therapy includes individual therapy, goals groups, feelings groups, reflection groups, issues groups, psychoeducational Social Thinking and Zones of Regulation groups, recreation therapy, etc.
There is a drastic difference between a traditional behavioral and neurobehavioral milieu for this population, as described below:
Sophisticated neuropharmacological treatments geared stabilizing brain function and providing adequate control of explosive aggression and impulsivity, to remove or overcome the neurological barriers to successful treatment of these psychiatric disorders. Medication is targeted at specific areas of the brain.
While chemical restraints may be used for safety, the goal should be to treat the underlying brain disorder.
The treatment environment is also modified to take into account the fact that individuals with neurodevelopmental disorders are easily overstimulated.
The milieu is quieter and slower-paced, with many rest periods built into the schedule.
Limit setting is accomplished without confrontations that can lead to rage behavior.
It is a nurturing, rather than an authoritarian milieu, with an emphasis on redirection.
There should be positive praise when control is achieved.
There should be a concerted effort to avoid a punitive program, and all negative behavioral consequences (not necessarily safety precautions) should be kept brief (15 minutes to 24 hours at a maximum).
Social skills training and anger management should be an integral part of all nursing plans.
There should be a focus on avoiding power struggles, by encouraging negotiation to obtain needs and decreasing negative attention, by “picking battles”.
Staff use a positive approach, by telling service recipients what to do, rather than what not to do.
Staff should help service recipients gain insight into their coping skills and work to increase trigger awareness.
The Safe Behavior System is used, where the emphasis is on safe behavior and then more advanced treatment goals.
When someone is unsafe the only goal is to get safe. The 2/4 rule is used. 2 hours away from peers to de-escalate and 4 hours restricted to the unit.
Once safe, the goal is to be “on plan” or meeting goals. Once “on plan” the goal is to stay “on plan”.
A variety of teaching and behavioral shaping methods are used, including
Redirection- staff tells the service recipient what to do, not what to stop doing
Modeling and Demonstration
Mentoring- a certain staff provides individualized support for one service recipient.
Co-regulation- staff shows caring and affection, predicts needs and wants, and provides caring support during times of stress or crisis
The 2/4 rule
Activity by Activity- The service recipient will be held back from the next activity if disruptive or unsafe during the previous activity
Time-outs
Direct teaching
Role-playing
Redos or Do-overs
Restorative actions or repairs
Collaborative Problem Solving- engages staff and service recipients in a discussion to find more effective responses to impulsive misbehaviors
Staff uses an 80/20 rule which means 80% of the time they are providing praise and positive reinforcement and only 20% of the time, mild and brief consequences
Service recipients accumulate points to turn in at a points store for small tangible items and/or weekly points that can be cashed in for “big ticket” special privileges and rewards.
Service recipients do not lose points; they only earn points
Service recipients do not need to earn treatment or daily activities, such as meals off the unit and passes with family.
Well-defined logical consequences leveled at the severity of the problem behavior may be used in moderation.
Each unit has two dayrooms. Service recipients are assigned to a dayroom based on their developmental age, level of functioning, and diagnosis.
Sometimes there is not a good fit, and a dayroom reassignment may be considered and/or undertaken.
Developmentally younger service recipients who have more severe skills deficits are assigned to a dayroom with program and group content suited to their needs.
There is a highly structured daily schedule.
To effectively help these service recipients navigate transitions between activities, staff gives 15, 10, and 5-minute warnings before the change of activity.
The physical environment is modified to take into account safety concerns, have lots of space, address sensory concerns (e.g. noise), and reduce traumatic associations.
There is a staff-to-service recipient ratio of 1:5.
Keep up the good work
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