M.B.  is a 33-year old male (DOB: 07/02/65) who sustained a severe traumatic brain injury as the result of a work related fall of approximately 20 feet on December 8, 1993.  He was transferred to the Emergency Room at Wilson Memorial Hospital where he was in a coma with nonpurposeful and nonlocalized response to pain.  CT scan of the head revealed diffuse white matter shearing with diffuse cerebral edema and a left hemisphere brain contusion.  On December 14, 1993, he presented with increased cerebral edema, was transferred to UMC Hospitals in Chapel Hill, stabilized and returned to Wilson Memorial Hospital.  A follow-up CT scan revealed significant hydrocephalus and on January 13, 1994 a VP shunt was placed.  Upon improved neurological status, M.B.  was transferred to Pitt Memorial Hospital for acute rehabilitation on January 26, 1994 where he received two months of rehabilitation and was subsequently placed at Britt Haven Nursing Home in Wilson, North Carolina.  M.B. showed slow progress with several setbacks behaviorally.  On May 12, 1994, he was transferred to Learning Services for assisted living and continued rehabilitation.  Available information indicates that he sustained a previous head injury at approximately age 13 that resulted in minor speech problems.

Referral to the Florida Institute for Neurologic Rehabilitation, Inc. (FINR) is necessitated because of Mr. Baker's significant behavioral dysfunction including noncompliance, sexual disinhibition with females, physical aggression, property damage/destructive behavior, and multiple episodes of suicidal ideation ó some being described as attention seeking devices and ploys as well as manipulative behavior to obtain preferred reinforcing events through noncompliance and inappropriate behavior.  Other behavioral observations have included poor medication compliance, poor nutrition, and difficulty maintaining himself in regards to personal hygiene and self-care (dressing, showering).  Goals of placement at FINR include providing M.B. a safe and secure residential environment within a facility that specializes with traumatic brain injury and neurobehavioral difficulties secondary to insult, to improve physical functioning and mobility, to provide initial evaluation and treatment within the first month in the areas of occupational therapy and speech/language pathology to ascertain the appropriateness of continued clinical intervention, and to provide the opportunity for a supportive independent living environment if continuation of intensive therapies are not recommended or warranted. Based on a review of available information, M.B.  is accepted for admission for rehabilitation treatment to address the above stated goals.  At the same time, previous history suggests that Mr. Baker has had extreme difficulty since his closed head injury and continues to present with significant behavioral problems.  It is important that M.B. have the opportunity to be in a structured, secure residential program that provides contingency management, social skills acquisition opportunities, and motivational assistance for behavioral stability and self-regulation.  M.B. is appropriate for a 30-day period of evaluation and treatment.  It is anticipated that based upon M.B.'s history and available reports that have been reviewed that he will be placed in the supportive independent living program with significant behavioral management and intervention paired with recommended clinical intervention.  The overall objective will be to improve behavioral self-control skills, have appropriate medication management, and to provide functional avocational/vocational related behavior and opportunities.  Our focus in general will be the development of positive self-control and behavior management skills.  M.B. will be provided with teaching, practice, and training in a more natural environment that will be of greater benefit as opposed to a traditional rehabilitation program in which M.B. will participate in clinic-based treatment.  We will likely complete assessments and evaluations.  However, completion is dependent upon initial presenting behaviors of M.B.  The goal is a rapid transition to a daily program that consists primarily of on-campus avocational/vocational pursuits, social skills training, and practice in various residential skills.  Based on initial assessment results, therapists will develop prescriptive procedures and strategies that will be implemented by staff in these everyday living environments.  M.B. will be involved in an overall contingency management program in which success in a variety of areas contributes to increased reward and flexibility of programming.  It is likely that M.B.'s program will emphasize the following:

• Medical management.  Our medical staff including our neurologist, internist, neuropsychiatrist, and neuropsychologist will see M.B.  Medications will be evaluated and medical history carefully reviewed to address current pharmacological interventions.  Our goal will be to ensure, from a medical point of view, that M.B. has the potential for the highest possible functioning level with the appropriate medical management and pharmacological intervention necessary to ensure appropriateness for functional outcomes.  It should be noted that at times M.B. has been noncompliant in regard to his medication regime, with one rationale of noncompliance being changes or sudden adaptations to his structured programming as well as agitation and rigidity related to potential inconsistent staffing patterns, especially when related to females that M.B. perceived having a meaningful relationship with.  Records review indicates that M.B. wears glasses, has no stated allergies, and no seizure activity.  M.B. has had a low-fat/low-cholesterol/low-sodium diet in the past and a nurse-to-nurse consult is warranted to verify if that dietary protocol is in place at the current time.  It also should be noted that M.B.  must monitor intake as a dietary precaution.

• Teaching of prosocial skills and behavioral management. Reports indicate that M.B. demonstrates significantly reduced social skills.  He has been described as noncompliant with others; has difficulty tolerating frustration and delay; presents as a concrete, rigid in thought individual, who has difficulty tolerating change or deviation from a prescribed structured schedule; at times can be nonresponsive and withdrawn, engaging in passive-aggressive behavior; has difficulty regulating impulsivity, has been verbally abusive and physically aggressive; engages in property destruction when agitated and upset; and has had multiple episodes of suicidal ideation when perceived needs are not met. Our general emphasis in this area will be to teach positive alternatives in a very simple and consistent fashion.  We will provide a high level of support and supervision to M.B. to ensure that he maintains compliance with various activities and events and has few opportunities to engage in escape/avoidance behavior.  Staff who is with him will begin intensive teaching of basic social skills and self-control strategies through rehearsal, practice, and role-play.  If M.B. becomes frustrated with limits and other program components, these episodes will be used to further teach and reinforce appropriate behaviors.  Likely areas for intensive teaching include increasing his ability to accept supervision, correction, and teaching, improve his ability to accept frustration, delay and being told "no," and increasing his ability to cooperate and assist others.  We will also teach alternative replacement behaviors including concrete, simple self-control techniques with the goal of decreasing impulsivity and significant behavioral issues that have caused previous multiple psychiatric placements as well as involvement with the legal system.

• Improving skills associated with activities of daily living, life management skills, and work/leisure activities.  The development of skills, attitudes, and behavior for the aforementioned areas are crucial for continued success and quality of life for M.B..  We anticipate M.B.'s involvement in vocational programming at the Florida Institute, this intervention being used as a training ground and environment rather than an opportunity of specific job skills.  The overall goal is to provide M.B.  with the type of responses that enable later success in social interactions with peers, other adults, or in vocational/avocational opportunities.  Avocational/vocational programming will emphasize skills such as increased punctuality, working and being able to maintain self on assigned tasks, improving his ability to accept instruction and constructive feedback from others, increasing overall avocational/vocational readiness including adopting expected standards of dress and grooming, and maintaining tasks and performance throughout a prescribed time period.  M.B.  reportedly is totally independent in regard to personal and self care.  He can dress, groom, and take care of himself very well.  It is reported that he usually appears neat and clean. This becomes significant because M.B.  has had psychiatric placements because of his lack of motivation, noncompliance, and/or his lack of ability to care for himself in the appropriate manner or appropriate situations, circumstances, and weather conditions.  (Attention seeking ploys through non-compliance) As in other areas of treatment, we will utilize frequent, repetitive, consistent teaching and practice throughout the day and evening to encourage and positively reinforce M.B.'s self-reliance in the areas of personal self-care and appearance.

• Cognitive evaluation and treatment.  M.B.  has been described as demonstrating reduced judgment, reduced problem solving, reduced reasoning, with increased impulsivity and irritability.  It appears based upon behavioral reports that he has the cognitive understanding to engage in maladaptive and manipulative behaviors to try to obtain preferred reinforcing events.  If M.B.  has learned to obtain reinforcing events through maladaptive behaviors, then one can assume that he also has the capability of learning how to obtain preferred reinforcing events through engagement of appropriate prosocial skills and behavior.  Our general approach will be to establish his entry-level performance through clinic-based assessment and then intervene with prescriptive procedures and protocols in a more natural training environment.  Initially, focus is likely to occur in areas that are not particularly personally relevant to minimize his frustration and emotional responding.  With these somewhat neutral issues, we will begin teaching simple problem solving strategies that are standardized and routine.  As M.B.'s ability to use strategies increases there will be concentration on behavioral and content issues that are more personally relevant to him.  We will work with M.B.  to transfer improved judgment and improved problem solving to increase performance in routine daily situations, specifically in regard to developing improved behavioral self-regulation and safety awareness skills in his daily life.

• Physical functioning and mobility / speech & language. M.B. currently presents in a wheelchair and can use the wheelchair independently.  Available information indicates that he has ambulated at least 40-50 feet with a rolling walker with stand-by guard.  Foot placement has been described as inconsistent, and balance more decreased when standing versus sitting.  Bed mobility is independent, as are transfers.  Adaptive equipment utilized includes wheelchair, shower chair, and four-leg walker.  Utilization of a quad-cane has been recommended by physical therapist.  There is demonstrated right-sided upper extremity weakness, and being naturally right-handed M.B.  has compensated with his left hand for daily tasks.  He can grasp with his right hand, but there appears to be poor fine motor coordination.  There will be an initial assessment regarding physical functioning and mobility.  It is assumed that if there can be some initial progress with behavioral compliance that M.B. can improve physical functioning and mobility with clinical intervention paired with prescriptive protocols utilized throughout his day.M.B. presents with severe dysarthria with vocalization of imprecise consonants and decreased loudness due to poor respiratory and phonatory coordination.  His vocal quality is severely breathy for all productions.  His ability to sustain vowel sounds is severely impaired.  When comparing duration and production of voiceless sounds (/s/) versus voiced sounds (/z/) M.B.  produced a ratio of eight seconds to one second which is well below the norm of a one-to-one ratio.  His speech presents at approximately 50% intelligibility without compensatory strategies by subjective judgment.  There are mild receptive language deficits when presented with lengthy, more complex information.  Expressive evaluation via the Lightwriter augmentative communication device is WFL with production of full sentences.  Verbal communication is severely compromised by the severe dysarthria.  It was recommended on April 22, 1998 that M.B. receive an otolaryngology assessment to visualize the integrity of vocal cords and determine the appropriateness for speech therapy.  If this assessment has not been completed, it is recommended that it be done as soon as possible after admission to FINR.

• Ongoing family education.  We would like to extend an invitation for M.B.'s family to become involved with his program is well as participate in ongoing family education.  The goal is to assist significant others in developing the skills necessary to ensure the most positive environment for M.B. , as well as to be able to implement and utilize some behavioral management strategies and appropriate teaching skills for the maintenance of M.B.'s anticipated projected gains.

Client Progress:
M.B.  is continuing to live in the Supported Independent Living program at the Florida Institute for Neurologic Rehabilitation. His current level of supervision is periodic checks every 15 minutes on all shifts. M.B. continues to participate in a program of independent physical and utilization of the winnie walker to support ambulation, and work on independence with all transfers. He is involved in a social skills interaction group with Occupational Therapy.

Due to his difficulties with speech intelligibility and long-standing dysarthria, he uses an augmentative communication device with excellent proficiency.  This device, (Lite Writer) is portable and is also utilized to keep track of scheduled therapies, and activities within the Florida Institute and the outside community.  M.B.  enjoys the opportunity to generalize his skills in community activities such as going to the shopping mall, dining out, and weekly town trips.  He has provided the facility with an ongoing chronology of these activities through his hobby, photography, and most recently he attended the Winston Cup Car Race in Miami, and visited his family for Thanksgiving.  M.B.  has made remarkable progress in his ability to demonstrate independence in personal self-care and activities of daily living.  He has shown a marked decrease in his demonstration of maladaptive behaviors as a way to receive attention and has found through his augmentative communication device and hobby a way to redirect his energies in a positive manner.  When asked to show his photography to the Web Development Committee, he was willing to wait until the developer and designer had time to discuss his photography, he even scheduled them to visit him during his free time in his residence by checking his schedule on the Lite Writer and appropriately responding.  Waiting for a better time did not elicit any negative response rather a positive redirection by the client of an alternative time to visit with him. Mr. Baker will begin to work in a sheltered environment and continue to focus on a decrease in maladaptive behaviors.  Productive use of his leisure time and hobbies will also give him an opportunity to use his newly acquired social skills in the interaction with others and in other environments.  M.B's successes have been generalized to the outside environments such as his family home and

During group outing activities.  The continuity provided in the supported living environment at the Florida Institute has stopped the revolving door of psychiatric placements by allowing the client an opportunity to flourish within a safe non-threatening environment of his peers and with those individuals who specialize in the treatment of traumatic brain injury and resulting neurobehavioral difficulties.